DENOVA Score Calculator – Enterococcus faecalis Endocarditis Risk

Clinical calculation support · Verify results before clinical use

DENOVA Score

Assess endocarditis risk in adults with monomicrobial Enterococcus faecalis bacteremia.

—Score / 6

Population eligibility

The original score was developed for adults with monomicrobial E. faecalis bacteremia. Confirm eligibility before scoring.

Patient age 18 years or older

Blood culture confirms monomicrobial E. faecalis bacteremia

Duration of symptoms ≥7 days

Symptoms compatible with infective endocarditis for at least 7 days before the first positive blood culture was obtained.

+1 point

No0 points

Yes+1 point

Embolization

Clinical signs or imaging findings compatible with septic embolization.

+1 point

No0 points

Yes+1 point

Number of positive blood cultures ≥2

At least two positive blood cultures for E. faecalis.

+1 point

No0 points

Yes+1 point

Origin of infection unknown

No focal infection meeting the study definition as a likely source: at least two of typical symptoms/signs, isolation of E. faecalis at the suspected site, and compatible imaging.

+1 point

No — source identified0 points

Yes — unknown+1 point

Valve disease

Predisposing native valve disease, previous infective endocarditis, or a prosthetic heart valve.

+1 point

No0 points

Yes+1 point

Auscultation of heart murmur

A heart murmur documented on clinical examination.

+1 point

No0 points

Yes+1 point

—DENOVA

Risk stratification

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Clinical interpretation

Criterion	Finding	Points

A score below 3 must not be used to rule out infective endocarditis or automatically withhold echocardiography. A 2026 prospective multicentre external validation reported 79.2% sensitivity and 83.0% specificity at the ≥3 threshold. Clinical suspicion and guideline recommendations take precedence.

About the DENOVA Score

The DENOVA score is a six-item clinical prediction score developed to estimate the risk of infective endocarditis in adults with monomicrobial Enterococcus faecalis bacteremia. Each criterion contributes one point, producing a total score from 0 to 6.

Variables and points

Variable	Definition	Points
D — Duration	Symptoms compatible with IE ≥7 days before first positive blood culture	+1
E — Embolization	Clinical or imaging evidence of embolization	+1
N — Number	≥2 positive blood cultures for E. faecalis	+1
O — Origin	No focal source meeting the study definition (≥2 of typical symptoms/signs, E. faecalis isolated at site, compatible imaging)	+1
V — Valve disease	Predisposing native valve disease, previous IE, or prosthetic valve	+1
A — Auscultation	Heart murmur on auscultation	+1

Score threshold

DENOVA ≥3 is the originally proposed threshold for identifying patients at increased risk of IE and guiding echocardiographic evaluation. The original retrospective derivation and validation cohorts reported sensitivity of 100% and specificity of 83–85% at this threshold. These estimates should not be assumed to apply to every population.

Important evidence update

A prospective international multicentre external validation published in 2026 included 543 adults with monomicrobial E. faecalis bacteremia; 125 (23.0%) had IE. At DENOVA ≥3, sensitivity was 79.2% (95% CI 71.0–85.9) and specificity was 83.0% (95% CI 79.1–86.5). Thus, a low score does not reliably exclude IE.

Clinical Use and Limitations

Use this score only after confirming the intended population and microbiology. It was not developed for Enterococcus faecium bacteremia, polymicrobial bacteremia, or pediatric patients.

Guideline context

The 2023 ESC Guidelines state that echocardiography should be considered in E. faecalis bacteremia (Class IIa, Level B). DENOVA should support, not replace, clinical assessment and guideline-directed evaluation.

Practical cautions

Do not use a score of 0–2 as a stand-alone rule-out test.
Do not delay echocardiography when clinical suspicion is meaningful or the patient is unstable.
Consider TTE/TEE according to clinical findings, prosthetic material, persistent bacteremia, embolic events, and the overall Endocarditis Team assessment.
Score each item using information available at the time of clinical assessment and document uncertainty where relevant.

References

Berge A, Krantz A, Östlund H, Nauclér P, Rasmussen M. The DENOVA score efficiently identifies patients with monomicrobial Enterococcus faecalis bacteremia where echocardiography is not necessary. Infection. 2019;47(1):45–50. DOI: 10.1007/s15010-018-1208-3.

Danneels P, Chabrun F, Picard L, et al. Enterococcus faecalis endocarditis risk assessment in patients with bacteremia: External validation of the DENOVA score. Journal of Infection. 2023;87(6):571–573. DOI: 10.1016/j.jinf.2023.09.001.

Varisco B, Piovani D, Rosselli Del Turco E, et al.; ESGBIES and EfFAECT study groups. Clinical utility of the DENOVA score for predicting infective endocarditis in Enterococcus faecalis bacteraemia: external validation with decision curve analysis. Clinical Microbiology and Infection. 2026;32(7):1144–1151. DOI: 10.1016/j.cmi.2026.02.019.

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 an educational clinical decision-support aid and is not a diagnostic test. DENOVA does not establish or exclude infective endocarditis. Interpret the result in the context of microbiology, clinical presentation, echocardiographic findings, current guidelines, and specialist assessment. Do not use this score as the sole basis for deciding whether echocardiography is indicated.