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Chapter 40: Infective Endocarditis

Michael G. W. Camitta; William J. Steinbach; Jennifer S. Li

DEFINITIONS AND EPIDEMIOLOGY

Infective endocarditis (IE) denotes infection of the endocardial surface of the heart and implies the physical presence of microorganisms in the lesion. Although the heart valves are most commonly affected, the disease may also occur within the heart in the location of congenital septal defects or on the endocardial surface in areas of turbulent flow. Extracardiac infections of arteriovenous or arterioarterial shunts (patent ductus arteriosus), infection related to structural aortic arch anomalies, and infections of prosthetic materials such as vascular occluders and stents can also be included in this definition, due to similar clinical manifestations. Unfortunately, variability in the clinical presentation continues to make the diagnosis of IE clinically challenging. The Duke Criteria for the Diagnosis of Infective Endocarditis have been developed1 and modified.2 These criteria (listed in Tables 40-1 and 40-2) have been validated in multiple studies and have been shown to be superior to other criteria for the diagnosis of IE in the pediatric population.3–5

TABLE 40-1Definition of Infective Endocarditis According to Modified Duke Criteria
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TABLE 40-1 Definition of Infective Endocarditis According to Modified Duke Criteria
Definite infective endocarditis
 Pathologic criteria (one of the following)
  Microorganisms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen
  Pathologic lesions; vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis
 Clinical criteria (one of the following)
  2 major criteria
  1 major criterion and 3 minor criteria
  5 minor criteria
Possible infective endocarditis
  1 major criterion and 1 minor criterion
  3 minor criteria
Rejected (one of the following)
 Firm alternate diagnosis explaining evidence of infective endocarditis
 Resolution of infective endocarditis syndrome with antibiotic therapy for ≤4 days
 No pathologic evidence of infective endocarditis at surgery or autopsy, with antibiotic therapy for ≤4 days
 Does not meet criteria for possible infective endocarditis, as above

Reproduced with permission from Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000 Apr;30(4):633-638.

TABLE 40-2Definitions of Terms Used in Modified Duke Criteria for Diagnosis of Infective Endocarditis
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TABLE 40-2 Definitions of Terms Used in Modified Duke Criteria for Diagnosis of Infective Endocarditis
...
Major criteria
 Blood culture positive for IE
  Typical microorganisms consistent with IE from 2 separate blood cultures:
   Viridans streptococci, Streptococcus bovis, HACEK group, Staphylococcus aureus
   Community-acquired enterococci, in the absence of a primary focus
  Microorganisms consistent with IE from persistently positive blood cultures, defined as follows:
   At least 2 positive cultures or blood samples drawn > 12 hours apart
   All of 3 or a majority of ≥ 4 separate cultures of blood (with first and last sample drawn at least 1 hour apart)
   Single positive blood culture for Coxiella burnetti or antiphase I IgG antibody titer > 1 : 800

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