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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 references 25

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          Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis.

          Although the sensitivity and specificity of the Duke criteria for the diagnosis of infective endocarditis (IE) have been validated by investigators from Europe and the United States, several shortcomings of this schema remain. The Duke IE database contains records collected prospectively on >800 cases of definite and possible IE since 1984. Databases on echocardiograms and on patients with Staphylococcus aureus bacteremia at Duke University Medical Center are also maintained. Analyses of these databases, our experience with the Duke criteria in clinical practice, and analysis of the work of others have led us to propose the following modifications of the Duke schema. The category "possible IE" should be defined as having at least 1 major criterion and 1 minor criterion or 3 minor criteria. The minor criterion "echocardiogram consistent with IE but not meeting major criterion" should be eliminated, given the widespread use of transesophageal echocardiography (TEE). Bacteremia due to S. aureus should be considered a major criterion, regardless of whether the infection is nosocomially acquired or whether a removable source of infection is present. Positive Q-fever serology should be changed to a major criterion.
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            New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service.

            This study was designed to develop improved criteria for the diagnosis of infective endocarditis and to compare these criteria with currently accepted criteria in a large series of cases. A total of 405 consecutive cases of suspected infective endocarditis in 353 patients evaluated in a tertiary care hospital from 1985 to 1992 were analyzed using new diagnostic criteria for endocarditis. We defined two "major criteria" (typical blood culture and positive echocardiogram) and six "minor criteria" (predisposition, fever, vascular phenomena, immunologic phenomena, suggestive echocardiogram, and suggestive microbiologic findings). We also defined three diagnostic categories: (1) "definite" by pathologic or clinical criteria, (2) "possible," and (3) "rejected." Each suspected case of endocarditis was classified using both old and new criteria. Sixty-nine pathologically proven cases were reclassified after exclusion of the surgical or autopsy findings, enabling comparison of clinical diagnostic criteria in proven cases. Fifty-five (80%) of the 69 pathologically confirmed cases were classified as clinically definite endocarditis. The older criteria classified only 35 (51%) of the 69 pathologically confirmed cases into the analogous probable category (p < 0.0001). Twelve (17%) pathologically confirmed cases were rejected by older clinical criteria, but none were rejected by the new criteria. Seventy-one (21%) of the remaining 336 cases that were not proven pathologically were probable by older criteria, whereas the new criteria almost doubled the number of definite cases, to 135 (40%, p < 0.01). Of the 150 cases rejected by older criteria, 11 were definite, 87 were possible, and 52 were rejected by the new criteria. Application of the proposed new criteria increases the number of definite diagnoses. This should be useful for more accurate diagnosis and classification of patients with suspected endocarditis and provide better entry criteria for epidemiologic studies and clinical trials.
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              New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings

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                Author and article information

                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
                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
                2583066
                10.1093/jac/dkn423
                dkn423
                18952617
                © 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

                Categories
                Original Research

                Oncology & Radiotherapy

                treatment, ie, diagnosis

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