Should We Use New Duke Criteria for Infective Endocarditis?

פוסט זה זמין גם ב: עברית

April 10, 2024

Written by Jason Lesnick

This external validation compared the 2023 Duke-International Society for Cardiovascular Infectious Diseases Diagnostic (ISCVID) Criteria against various other criteria for diagnosing infective endocarditis (IE) and found the 2023 Duke-ISCVID Criteria had the best test characteristics. Tomorrow, we’ll dive into the new criteria.

The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria

Duke…still making noise even after March Madness!
These authors analyzed data from 595 consecutive adult patients with suspected or confirmed IE referred to the IE team of Amsterdam University Medical Center from Oct 2016-Mar 2021. An international expert panel independently reviewed case summaries and assigned a final diagnosis of “IE” or “Not IE” which was used as the reference standard and compared to the “Definite” Duke-ISCVID classification. They also compared the 2023 Duke-ISCVID to the 2000 Modified Duke Criteria and the 2015 and 2023 European Society of Cardiology (ESC) Criteria.

For each criteria set they used the definitions for “Definite”, “Possible” and “Rejected” IE and their definitions of Major and Minor Criteria. For each case, two classifications were made – one with all available data including results from surgery and post-mortem examination, and another using only the clinical data available before surgery or death. If two experts disagreed, a third adjudicator ruled on the diagnosis; kappa was 0.72, and 88% of all cases had both adjudicators agree on the diagnosis. Notably, an expert adjudication panel was used previously in other studies validating other prior version of the Duke Criteria.

The data showed 67% (399) of patients were adjudicated as IE; 19% (111) had prosthetic valve IE, and 48 (8%) had cardiac implantable electronic device IE. The 2023 Duke-ISCVID Criteria were more sensitive (84.2%) than both the Modified Duke and 2015 ESC Criteria (74.9% and 80%, respectively; p < 0.001). The Duke-ISCVID Criteria were similarly sensitive but more specific than the 2023 ESC Criteria (94% vs 82%, p <0.001).

Sensitivity and specificity were compared to the reference standard provided by the adjudication panel where “Definite IE” was selected as a positive test while both “Possible IE” and “Rejected IE” constituted a negative test. The authors also calculated the same measures for Clinical Criteria only (excluding surgery and pathology findings).

The authors found sensitivity of the 2023 Duke-ISCVID Criteria to be 84.2% (95%CI 80.3-87.7) and specificity 93.9% (95%CI 89.6-96.8) when including surgery and pathology information, while without these sensitivity dropped to 79% (95%CI 74.6-82.3) and specificity was unchanged.

A sensitivity analysis was performed looking at if “definite” and “possible” were classified as positive tests, and the 2023 Duke-ISCVID Criteria in that case had 99% sensitivity but specificity dropped to 21%.

How will this change my practice?
I tend to agree with the authors who concluded that the 2023 Duke-ISCVID Criteria should supplant other criteria and be the preferred tool for attempting to diagnose IE. Based on this study, when considering the diagnosis of IE I will reference the 2023 Duke-ISCVID Criteria when discussing this with the admitting team. I also find it useful to know that if a patient is classified as “rejected” the NPV was found to be 98% in this study.

External Validation of the 2023 Duke – International Society for Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis. Clin Infect Dis. Published online February 8, 2024. doi:10.1093/cid/ciae033. PMID: 38330166.

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