Validation Studies

After the Duke criteria were published, a number of studies appeared that compared the von Reyn criteria to the Duke criteria for the diagnosis of IE [13,27-29]. These studies utilized pathologically confirmed cases of IE and retrospectively assessed the ability of the von Reyn and the Duke criteria to categorize the probability of IE. In general, the Duke criteria

Table 6.3. von Reyn Criteria for Diagnosis of Infective Endocarditis Definite

Direct histologic evidence of infective endocarditis from surgery or autopsy

Bacteriology (Gram stain or culture) of valvular vegetation or peripheral embolus Probable

Persistently positive blood cultures plus ONE of the following: New regurgitant murmur

Predisposing heart disease AND vascular phenomena

Negative or intermittently positive blood culture plus ALL of the following: Fever

New regurgitant murmur

Vascular phenomena (petechiae, splinter hemorrhages, conjunctival hemorrhages, Roth spots, Osler's nodes,Janeway lesions, aseptic meningitis, glomerulonephritis, peripheral emboli, central nervous system emboli, coronary emboli, peripheral emboli) Possible

Persistently positive blood culture plus ONE of the following:

Predisposing heart disease (definite valvular or congenital disease or cardiac Prosthesis excluding permanent pacemakers) Vascular phenomena

Negative or intermittently positive blood culture plus ALL of the following: Fever

Predisposing heart disease Vascular phenomena Rejected

Endocarditis unlikely, alternative diagnosis generally apparent

Endocarditis likely, empiric antibiotic therapy warranted

Culture negative endocarditis diagnosed clinically but excluded by postmortem

Source:Adapted from [25].

were more likely to have diagnosed cases as definite IE (80-100%) and would not have rejected any of the cases of proven endocarditis. On the other hand, the von Reyn criteria defined 50% of these cases as probable. More importantly, the von Reyn criteria would have rejected 20-50% of the cases proven pathologically to be IE. The Duke criteria also classified 75% of confirmed prosthetic valve endocarditis (PVE) cases as definite and rejected no cases of PVE. The von Reyn criteria, however, rejected 20% of these confirmed cases of PVE [30]. Dodds et al. assessed the clinical cases rejected by the Duke criteria and determined the negative predictive value to be at least 92% [31]. Therefore, at the present time, the Duke criteria are the standard diagnostic criteria for patients with suspected IE.

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