Infective Endocarditis Scores

VIRSTA Score Calculator – Infective Endocarditis Risk in Staphylococcus aureus Bacteremia

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VIRSTA Risk Assessment

Select Yes or No for each clinical predictor and enter the C-reactive protein level.

— Score

Clinical predictors

Cerebral or peripheral emboli

Clinical or imaging evidence of cerebral or extracerebral embolic events.

+5 points

Meningitis

Clinical diagnosis of meningitis associated with the current Staphylococcus aureus bacteremia episode.

+5 points

Intracardiac device or previous infective endocarditis

Permanent intracardiac device or a history of infective endocarditis.

+4 points

Intravenous drug use

Current intravenous drug use.

+4 points

Pre-existing native valve disease

Known pre-existing native valvular heart disease.

+3 points

Persistent bacteremia at 48 hours

Positive follow-up blood culture at 48 hours after the first positive blood culture.

+3 points

Vertebral osteomyelitis

Vertebral osteomyelitis associated with the current bacteremia episode.

+2 points

Community or non-nosocomial healthcare-associated acquisition

SAB acquired in the community or in a non-nosocomial healthcare setting.

+2 points

Severe sepsis or septic shock

Severe sepsis or septic shock, as clinically established.

+1 points

Enter the measured CRP value. The VIRSTA criterion is positive only when CRP is greater than 190 mg/L.

mg/L
— VIRSTA
Infective endocarditis risk category
Complete all variables
The score will be calculated when all clinical predictors and the CRP value have been entered.
Clinical interpretation Complete the assessment to view the VIRSTA risk category. Do not use this score as a substitute for clinical assessment or echocardiography decisions.

The original VIRSTA score was developed to estimate IE risk and prioritize echocardiography in adults with Staphylococcus aureus bacteremia. The score is not a diagnostic test and does not independently rule in or rule out infective endocarditis.

About the VIRSTA Score

The VIRSTA score is a clinical prediction score developed to estimate the risk of infective endocarditis (IE) in adults with Staphylococcus aureus bacteremia (SAB), and to help prioritize echocardiographic evaluation.

It includes 10 clinical and laboratory predictors. Each predictor contributes a predefined number of points to the total score.

Variables and points

PredictorPoints
Cerebral or peripheral emboli+5
Meningitis+5
Intracardiac device or previous infective endocarditis+4
Intravenous drug use+4
Pre-existing native valve disease+3
Persistent bacteremia at 48 hours+3
Vertebral osteomyelitis+2
Community or non-nosocomial healthcare-associated acquisition+2
Severe sepsis or septic shock+1
CRP >190 mg/L+1

Risk categories

Total scoreVIRSTA categoryOriginal derivation cohort
0–2Low risk1.1% IE; NPV 98.8%
≥3High risk17.4% IE

These event rates are observations from the original derivation cohort and are not individualized probabilities. In a Dutch external validation cohort of 477 patients, VIRSTA sensitivity was 98.9% and NPV was 99.3%; 70.9% of patients were classified as high risk. Predictive values vary with disease prevalence and the population being assessed.

Clinical use and current guidance

Use VIRSTA as an adjunct to clinical assessment and to help prioritize further evaluation. The 2026 IDSA/ESCMID consensus suggests routinely performing transthoracic echocardiography in all adults with SAB. A low VIRSTA score should therefore not be used by itself to omit TTE.

In adults with SAB and a negative TTE, the 2026 consensus suggests TEE when features such as an intracardiac device, predisposing valve disease or previous IE, positive follow-up cultures at or beyond 48 hours, embolic events, or multiple non-contiguous infection foci are present. Community-onset SAB and injection drug use may also warrant consideration of TEE.

References

Tubiana S, Duval X, Alla F, et al.; VIRSTA/AEPEI Study Group. The VIRSTA score, a prediction score to estimate risk of infective endocarditis and determine priority for echocardiography in patients with Staphylococcus aureus bacteremia. Journal of Infection. 2016;72(5):544–553. DOI: 10.1016/j.jinf.2016.02.003.
van der Vaart TW, Prins JM, Soetekouw R, et al. Prediction Rules for Ruling Out Endocarditis in Patients With Staphylococcus aureus Bacteremia. Clinical Infectious Diseases. 2022;74(8):1442–1449. DOI: 10.1093/cid/ciab632.
Infectious Diseases Society of America (IDSA) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID). IDSA/ESCMID 2026 Consensus Statements on Staphylococcus aureus Bacteremia: Risk Stratification, Diagnostic Evaluation, and Management of Adults and Children. Published September 9, 2026. Official guideline.
European Society of Cardiology (ESC). 2023 ESC Guidelines for the management of endocarditis. European Heart Journal. 2023;44(39):3948–4042. DOI: 10.1093/eurheartj/ehad193.
Clinical disclaimer: This calculator is intended for healthcare professionals as a clinical decision-support aid. VIRSTA is a risk stratification instrument for adults with Staphylococcus aureus bacteremia, not a diagnostic criterion for infective endocarditis. A low score does not exclude IE and must not independently determine whether echocardiography is performed. Interpret the result in the context of the patient's clinical presentation, microbiology, imaging, comorbidities, and current institutional guidance.
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