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      Development and assessment of a new early scoring system using non-specific clinical signs and biological results to identify children and adult patients with a high probability of infective endocarditis on admission

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          Abstract

          Objectives

          The aim of this study was to assess whether non-specific clinical signs or biological results can identify patients with a high probability of infective endocarditis (IE) to improve outcome.

          Patients and methods

          All patients tested for IE were included in a cohort and classified according to the modified Duke criteria. Patients with rejected endocarditis served as controls. Univariate and multivariate analyses were performed, and a score was calculated by adding 1 when a variable independently associated with IE (excluding major Duke criteria) was present and 0 when the variable was absent. A second score for patients with prior valvular damage (PVD) was also used. Scores were evaluated using the ROC curve method.

          Results

          IE was diagnosed in 402 of 2039 participants (19.7%). By multivariate analysis, PVD, fever, emboli, stroke, splenomegaly, finger clubbing, leucocytosis and erythrocyte sediment rate >50 were independently associated with IE. The rate of IE increased significantly from 4% (10/254) for a score of 0 to 83% (10/12) for a score of 6 in all patients, and from 9.5% (23/241) to 100% (10/10) in patients with PVD. The area under the ROC curve was 0.75 for the first score and 0.7 for the second. In a prospective study of 117 patients with suspicion of IE, the proportion of confirmed IE was 19% and the area under the ROC curve was 0.72.

          Conclusions

          This simple score can be used to identify patients with a high probability of IE, in the emergency room or on admission, to speed up diagnosis, or to initiate empirical antimicrobial therapy without replacing the modified Duke criteria.

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          Most cited references20

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          New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings

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            Q fever serology: cutoff determination for microimmunofluorescence.

            Q fever, a worldwide zoonosis caused by Coxiella burnetii, lacks clinical specificity and may present as acute or chronic disease. Because of this polymorphism, serological confirmation is necessary to assess the diagnosis. Although microimmunofluorescence is our reference technique, the cutoff titers that are currently used to make a diagnosis of active or chronic Q fever were determined years ago with limited series of patients and sera. We determined the titers of immunoglobulin G (IgG), IgM, and IgA against both phases (I and II) of Coxiella burnetii. Rheumatoid factor was removed before testing IgM and IgA. We report here the various cutoff titers and the kinetics of antibody development from 2,218 first serum samples of patients, among whom 208 suffered from acute Q fever and 53 had chronic Q fever. In active Q fever, we have defined a low cutoff (phase II IgG titer or = 200 and phase II IgM titer > or = 50) over which the diagnosis can be made. For chronic Q fever diagnosis, phase I IgA titers are not contributive despite previous works claiming their usefulness; a phase I IgG titer of > or = 800 is highly predictive (98%) and sensitive (100%). We have also studied the possibility of rejecting or evoking the diagnosis of chronic Q fever by phase II IgG and IgA titers. This method is useful when phase I testing is not available, but the sensitivity remains low (57%).
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              Diagnosis and management of infective endocarditis and its complications.

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                Author and article information

                Journal
                J Antimicrob Chemother
                jac
                jac
                Journal of Antimicrobial Chemotherapy
                Oxford University Press
                0305-7453
                1460-2091
                December 2008
                24 October 2008
                24 October 2008
                : 62
                : 6
                : 1434-1440
                Affiliations
                [1 ]Unité des Rickettsies, Faculté de Médecine, Université de la Méditerranée , 27 Boulevard Jean Moulin, 13385 Marseille Cedex 05, France
                [2 ]Department of Cardiology, Hôpital de la Timone, 264 rue Saint Pierre, 13385 Marseille Cedex 05, France
                [3 ]Service of Internal Medicine, Hôpital de la Conception, 147 Boulevard Baille, 13385 Marseille Cedex 05, France
                [4 ]Service of Internal Medicine, Hôpital de la Timone, 264 rue Saint Pierre, 13385 Marseille Cedex 05, France
                Author notes
                [* ]Corresponding author. Tel: +33-4-91-32-44-80; Fax: +33-4-91-38-77-72; E-mail: Didier.Raoult@ 123456gmail.com
                Article
                dkn423
                10.1093/jac/dkn423
                2583066
                18952617
                b90a27fd-aa78-4a48-9264-c5ed8f1cff81
                © The Author 2008. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

                The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

                History
                : 8 July 2008
                : 6 August 2008
                : 5 September 2008
                : 14 September 2008
                Categories
                Original Research

                Oncology & Radiotherapy
                diagnosis,ie,treatment
                Oncology & Radiotherapy
                diagnosis, ie, treatment

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