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Duke's criteria

The Duke criteria are used to diagnose infective endocarditis (IE). Here's a quick overview before I pull the full details from the medical library:
  • Diagnosis requires 2 major, 1 major + 3 minor, or 5 minor criteria
  • Major criteria include positive blood cultures and echocardiographic evidence of endocardial involvement
  • Minor criteria include predisposing conditions, fever, vascular/immunologic phenomena, and microbiological evidence not meeting major criteria
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"Duke criteria" AND "infective endocarditis"

I found a 2023 updated Duke Criteria table and the classic Modified Duke Criteria in multiple authoritative textbooks. Let me read the most current versions.
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I now have comprehensive data from both the Modified Duke Criteria (classic) and the 2023 updated Duke Criteria. Let me also get the physical exam and immunologic criteria from the 2023 version.
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Duke Criteria for Infective Endocarditis (IE)

The Duke criteria are a standardized diagnostic framework for infective endocarditis, originally proposed in 1994 and modified in 2000 (Li et al.). In 2023, they were further updated to the 2023 Duke/ISCVID Criteria (Fowler VG et al., Clin Infect Dis 2023).

Diagnostic Classification

CategoryClinical Criteria
Definite IE2 major criteria, OR 1 major + 3 minor, OR 5 minor criteria
Possible IE1 major + 1 minor, OR 3 minor criteria
RejectedFirm alternate diagnosis; OR resolution with antibiotics ≤4 days; OR no pathologic evidence at surgery on antibiotics ≤4 days; OR criteria for possible IE not met
Pathologic criteria (positive culture/histology from vegetation, abscess, prosthetic valve, or embolus) alone are sufficient for Definite IE.

MAJOR Criteria

A. Microbiologic Criteria (either of the following)

1. Positive blood cultures:
  • Typical IE organisms (Viridans streptococci, S. gallolyticus [formerly S. bovis], S. aureus, HACEK group, community-acquired enterococci) from 2 separate blood culture sets
  • Organisms that occasionally/rarely cause IE from 3 or more separate sets
  • Persistently positive cultures: ≥2 drawn >12 hours apart, or ≥3 of ≥4 drawn with first and last ≥1 hour apart
2. Positive laboratory test (new in 2023):
  • Positive PCR or nucleic acid-based test from blood for Coxiella burnetii, Bartonella spp., or Tropheryma whipplei
  • C. burnetii anti-phase I IgG titer >1:800, or isolated from a single blood culture
  • IgG titer >1:800 for Bartonella henselae or Bartonella quintana by indirect immunofluorescence

B. Imaging Criteria (new in 2023 - expanded beyond echo alone)

1. Echocardiography and/or cardiac CT (any of the following):
  • Vegetation, valvular/leaflet perforation, aneurysm, abscess, pseudoaneurysm, or intracardiac fistula
  • Significant new valvular regurgitation (compared with prior imaging)
  • New partial dehiscence of prosthetic valve
2. ¹⁸F-FDG PET/CT:
  • Abnormal metabolic activity (at least 3 months after implantation) involving a native or prosthetic valve, ascending aortic graft, intracardiac device leads, or other prosthetic material

C. Surgical Major Criterion (new in 2023)

  • Evidence of IE observed by direct inspection during cardiac surgery, in the absence of major microbiologic or imaging criteria

MINOR Criteria

A. Predisposing conditions

  • Previous history of IE
  • Prosthetic valve or previous valve repair
  • Congenital heart disease
  • More than mild valvular regurgitation or stenosis (any etiology)
  • Endovascular cardiac implantable electronic device (CIED)
  • Hypertrophic obstructive cardiomyopathy (HOCM)
  • Injection drug use

B. Fever

  • Temperature >38°C (100.4°F)

C. Vascular phenomena

  • Major arterial emboli, septic pulmonary infarcts, cerebral or splenic abscess, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, Janeway lesions, purulent purpura, thromboembolic phenomena

D. Immunologic phenomena

  • Glomerulonephritis, Osler nodes, Roth spots, positive rheumatoid factor, immune complex-mediated phenomena

E. Microbiologic evidence (falling short of major)

  • Positive blood cultures for an IE-consistent organism not meeting major criteria
  • Positive culture/PCR/sequencing from a sterile body site other than cardiac tissue, prosthesis, or embolus

F. Imaging criteria (minor, new in 2023)

  • Abnormal ¹⁸F-FDG PET/CT within 3 months of prosthetic valve/device implantation (those at >3 months = major criterion)

G. Physical examination (if echocardiography unavailable)

  • New valvular regurgitation on auscultation (worsening of a pre-existing murmur is not sufficient)

Key Mnemonics & Pearls

Classic peripheral stigmataMechanism
Osler nodesTender nodules on fingertips/toes - immune complex deposition (minor criterion)
Janeway lesionsNon-tender hemorrhagic macules on palms/soles - septic emboli (vascular, minor criterion)
Roth spotsRetinal hemorrhages with pale center - immune complex (minor criterion)
Splinter hemorrhagesSubungual - vascular emboli (minor criterion)
HACEK organisms (minor causes, need 3+ culture sets): Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella
Key 2023 updates vs. Modified Duke Criteria:
  1. Nuclear imaging (PET/CT) added as major imaging criterion
  2. Molecular diagnostics (PCR, NAT) for fastidious organisms added as major microbiologic criterion
  3. Surgical inspection added as a new major criterion
  4. Predisposition list expanded to include CIED, HOCM, prior IE
  5. Physical exam criterion added for resource-limited settings
Sources: Braunwald's Heart Disease, 11th Ed. (Table 80.3); Textbook of Clinical Echocardiography (Table 14.1 - 2023 Duke/ISCVID Criteria); Fowler VG et al., Clin Infect Dis 2023
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