Clinical Chemistry 55:2
295–304 (2009)
Lipopolysaccharide-Binding Protein:
A New Biomarker for
Infectious Endocarditis?
Tanja Vollmer,1 Cornelia Piper,2 Knut Kleesiek,1 and Jens Dreier1*
BACKGROUND: Infectious endocarditis (IE) is a bacterial
infection of the endocardium. Diagnosis is based on
results obtained from echocardiography, blood cul-
tures, and molecular genetic screening for bacteria and
on data for inflammatory markers such as the leuko-
cyte (WBC) count and the C-reactive protein (CRP)
concentration. The aim of the present study was to
evaluate lipopolysaccharide-binding protein (LBP) as a
supportive biomarker for the diagnosis and therapeu-
tic monitoring of IE.
METHODS: We measured LBP and CRP concentrations
and WBC counts in 57 IE patients at hospital admis-
sion, 40 patients with noninfectious heart valve dis-
eases (HVDs), and 55 healthy blood donors. The pro-
gression of these 3 markers and the influence of cardiac
surgery on them were evaluated in 29 IE patients and 21
control patients.
RESULTS: Serum LBP concentrations were significantly
higher in IE patients [mean (SD), 33.41 (32.10) mg/L]
compared with HVD patients [6.67 (1.82) mg/L, P ⬍
0.0001] and healthy control individuals [5.61 (1.20)
mg/L]. The progression in the LBP concentration dur-
ing therapy of IE patients correlated with the changes in
the CRP concentration. The 2 markers were equally
influenced by antibiotic treatment and surgical
intervention.
CONCLUSIONS: Serial LBP measurement may provide an
effective and useful tool for evaluating the response to
therapy in IE patients. We found a strong correlation
between LBP and CRP concentrations; LBP has a ten-
dency to increase earlier in cases of reinfection.
© 2008 American Association for Clinical Chemistry
1
Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszen-
trum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad
Oeynhausen, Germany; 2 Klinik für Kardiologie, Herz- und Diabeteszentrum
Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad
Oeynhausen, Germany.
* Address correspondence to this author at: Institut für Laboratoriums- und
Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Univer-
Proteomics and Protein Markers
Infectious endocarditis (IE),3 a relatively rare disease
with an incidence of 30 per million population (1 ), is
associated with high rates of mortality and morbidity.
Rapid diagnosis of IE is critical for effective treatment.
Diagnosis is based primarily on the results of echocar-
diographic examinations and blood culture tests [Duke
criteria (2 )], as well as on the results of serology tests
and molecular genetic screening methods for bacteria
in cases of heart valve replacement (3, 4 ). The initial
diagnosis of IE can be difficult, however, because of
nonspecific clinical symptoms, negative results in
blood cultures, and ambiguous echocardiographic
findings. In this context, the availability of biomarkers
is of major interest. Several studies have investigated
the application and usefulness of important laboratory
markers for IE diagnosis (5–12 ). Other studies (13–16 )
have focused on the clinical usefulness of serum C-
reactive protein (CRP), a marker most frequently used
in Europe (13 ), in IE. CRP has been assumed to be
primarily an indicator of local bacterial infections, but
increased CRP concentrations have also been strongly
associated with various nonbacterial infectious dis-
eases, e.g., rheumatic disorders (17 ). CRP has been
shown to have a limited ability to distinguish between
bacterial and viral infections (18 ).
Lipopolysaccharide-binding protein (LBP), a gly-
cosylated 58-kDa protein produced predominantly in
hepatocytes, has recently been described as a promising
novel diagnostic marker for the diagnosis of local bac-
terial infection (19 –23 ). LBP is released constitutively
into the bloodstream upon acute-phase stimulation
(24 ). It has a high affinity for lipopolysaccharide (LPS)
and other bacterial-surface components (25 ). Binding
of LPS to LBP facilitates the transportation of endo-
toxin molecules to immune effector cells possessing
surface CD14 receptors and further activates the proin-
flammatory cascade (24, 26 ). Association of the LPS/
sitätsklinik der Ruhr-Universität Bochum, Georgstrasse 11, 32545 Bad Oeyn-
hausen, Germany. Fax ⫹49-5731-97-2307; e-mail jdreier@hdz-nrw.de.
Received March 4, 2008; accepted August 26, 2008.
Previously published online at DOI: 10.1373/clinchem.2008.106195
3
Nonstandard abbreviations: IE, infectious endocarditis; CRP, C-reactive protein;
LBP, lipopolysaccharide-binding protein; LPS, lipopolysaccharide; HVD, nonin-
fectious heart valve disease; WBC, leukocyte; CI, confidence interval.
295
LBP complex with HDL inactivates LPS, thereby pro-
tecting against LPS toxicity (24 ).
The aims of this study were to evaluate (a) the
clinical usefulness of LBP as a supportive biomarker for
IE diagnosis, (b) the applicability of LBP for monitor-
ing the response to antibiotic therapy, and (c) the in-
fluence of cardiac surgery on the progression of LBP
values in both IE patients and patients with noninfec-
tious heart valve disease (HVD). The use of LBP as a
marker was compared with the frequently used endo-
carditis markers CRP and the leukocyte (WBC) count.
Materials and Methods
PATIENTS AND CONTROLS
Between May 2005 and November 2007, serum sam-
ples were obtained from 57 patients with definite IE
diagnosed according to the Duke criteria. The caus-
ative pathogens were identified with standard blood-
culture methods or broad-range PCR of the gene for
bacterial 16S ribosomal DNA, as described previously
(27 ). Patients with immunosuppression, cardiogenic
shock, or septic shock were excluded. Three of the pa-
tients had experienced 2 independent episodes of IE.
Patients were subdivided into 4 groups according to
the duration of antibiotic treatment [0 –10 days (n ⫽
38), 11–20 days (n ⫽ 7), 21–30 days (n ⫽ 6), and ⬎30
days (n ⫽ 9)]. Serum samples were also collected from
40 control HVD patients before surgical intervention.
HVDs consisted of noninfectious and nonrheumatic
valve insufficiencies or stenosis. We measured serum
LBP values in 55 healthy blood donors to confirm the
previously determined reference interval of the com-
mercially available LBP assay.
To examine the progression in LBP and CRP con-
centrations and the WBC count, we collected serum
samples and EDTA-anticoagulated blood samples
from 29 IE patients and 21 control patients with HVD
during their admission at our hospital. Samples were
collected daily. The study protocol was approved by the
institutional review board, and all patients gave their
informed consent.
MEASUREMENT OF CRP, LBP, AND THE WBC COUNT
Serum samples were collected in serum Monovettes
(Sarstedt). The samples were clotted, centrifuged at
4000g for 10 min, and stored at ⫺70 °C within 2 days of
collection. Samples were stored at this temperature un-
til assayed.
Serum CRP was measured with the ultrasensitive
latex immunoassay CRP Vario (Abbott Diagnostics),
and the total LBP concentration in serum samples was
measured with a commercially available chemilumi-
nescence assay (IMMULITE LBP, Diagnostics Prod-
ucts Corporation/Siemens Healthcare Diagnostics) ac-
296 Clinical Chemistry 55:2 (2009)
cording to the manufacturer’s instructions. All samples
were tested in random order with controls and calibra-
tion curves incorporated into each run. Blood samples
were collected in EDTA Monovettes (Sarstedt), and
WBCs were counted directly with the Cell-Dyn 3500
(Abbott Diagnostics).
STATISTICAL ANALYSIS
All data are presented as the mean (SD). The Mann–
Whitney U-test and the Student t-test were used for
statistical analyses as appropriate, and the assumption
of a gaussian distribution was tested in all data sets with
the Kolmogorov–Smirnov test. We used Pearson and
Spearman correlation coefficients to assess correlations
between variables. P values ⬍0.05 were considered sta-
tistically significant. GraphPad Prism 4.0 software
(GraphPad Software) was used for statistical analyses.
Results
Table 1 summarizes the clinical characteristics of the
patients and the control cohorts. LBP was measured in
serum samples obtained from 57 patients with 60 epi-
sodes of IE, a control group of 40 HVD patients, and a
second control group of 55 healthy blood donors. We
confirmed the manufacturer’s LBP reference interval
in our healthy control population. Fig. 1A presents
scatter plots of LBP concentration for the 3 cohorts.
Serum LBP concentrations were increased in 58 epi-
sodes of IE, and the increases were independent of the
duration of antibiotic treatment. In 2 episodes, the LBP
concentration was within the reference interval. LBP
concentrations were significantly higher in IE patients
than in the 2 control groups [IE patients, 33.41 (32.10)
mg/L; HVD patients, 6.67 (1.82) mg/L; healthy blood
donor control group, 5.61 (1.20) mg/L] (see Fig. 1A).
The diagnostic sensitivity was 96.7% [95% confidence
interval (CI), 92.2%–100.0%], and the diagnostic
specificity was 87.5% (95% CI, 77.3%–97.7%) with re-
spect to the HVD patients and 94.5% (95% CI, 88.5%–
100.0%) with respect to the healthy controls. The mean
LBP concentration of the IE patient samples was 83.2%
higher than the mean concentrations of the control
groups.
With respect to the duration of antibiotic treat-
ment, LBP concentrations were considerably lower af-
ter 11–20 days and ⬎30 days of treatment [14.56 (5.29)
mg/L and 15.71 (8.05) mg/L, respectively], compared
with treatment for 0 –10 days [41.97 (37.20) mg/L]
(Fig. 1A, inset). Comparatively high LBP concentra-
tions were observed after 21–30 days of antibiotic treat-
ment [25.45 (7.30) mg/L]. The serum concentration of
CRP in patients upon hospital admission showed a
trend similar to that of LBP, with IE patients having
significantly higher concentrations than the individu-
LBP in Infectious Endocarditis

als in the 2 control groups [IE patients, 101.90 (81.67)

mg/L; HVD patients, 2.31 (2.19) mg/L; healthy blood Table 1. Demographic characteristics of
donor control group, 1.11 (1.18) mg/L] (see Fig. 1B). the patients.
Likewise, WBC counts were higher in IE patients
[10.54 ⫻ 109/L (5.51 ⫻ 109/L)] than in the HVD group Variable

[6.94 ⫻ 109/L (1.55 ⫻ 109/L)] and the healthy control IE patients

group [7.37 ⫻ 109/L (1.65 ⫻ 109/L)] (Fig. 1C). The Age, yearsa
diagnostic sensitivities were 95.0% (95% CI, 89.5%– Male (n ⫽ 42) 64.67 (14.05), 21–102
100.0%) for CRP and 26.7% (95% CI, 15.5%–37.9%) Female (n ⫽ 15) 66.00 (15.35), 41–89
for the WBC count. The diagnostic specificity for CRP
Affected valves, %
was 87.5% (95% CI, 77.3%–97.7%) with respect to the
HVD patients and 100% (95% CI, 93.5%–100%) with Native 70
respect to the healthy controls. Although the WBC Prosthetic 30
count had the lowest diagnostic sensitivity (26.7%), it Causative microorganism, no. of
had a high diagnostic specificity [100% (95% CI, patients
91.2%–100%) with respect to HVD patients and 96.3% Staphylococcus aureus 17
(95% CI 91.3%–100.0%) with respect to the healthy Coagulase-negative staphylococci 10
controls]. Combining the LBP and CRP markers pro- Streptococcus spp. 12
duced a diagnostic sensitivity of 95.8% (95% CI, Enterococcus spp. 12
92.2%–99.4%) and a specificity of 87.5% (95% CI, Others 6
80.3%–94.7%) with respect to HVD patients and
Culture-negative endocarditis 2
97.3% (95% CI, 94.3%–100.0%) with respect to the
Surgical intervention, no. of episodes
healthy controls.
LBP and CRP values were significantly higher (P ⬍ Yes 47
0.0014, and P ⬍ 0.0009, respectively) in the HVD con- No 13
trol group than in the healthy blood donor control HVD patients
group, although all observed LBP concentrations were Age, years
within the reference interval. In contrast, the WBC Male (n ⫽ 19) 61.63 (16.36), 29–82
counts in the 2 control groups were not significantly Female (n ⫽ 21) 73.19 (7.32), 59–86
different. Comparisons of LBP and CRP concentra-
Affected valves, %
tions and the WBC count according to the infecting
microorganisms showed no differences in mean values Native 100
for any of the variables tested (data not shown). The Prosthetic 0
examined markers had equivalent positive predictive Healthy blood donors
values (LBP, 87.9%; CRP, 91.9%; WBC count, 88.9%) Age, years
compared with the average of the 2 control groups. The Male (n ⫽ 28) 36.75 (10.51), 19–55
negative predictive values were 97.8% (LBP), 96.8% Female (n ⫽ 27) 37.96 (13.30), 19–64
(CRP), and 67.9% (WBC count). A correlation analysis
a
of LBP, CRP, and WBC values for IE patients showed a Age data are presented as the median (SD), range.
strong correlation between LBP and CRP concentra-
tions (Spearman rank correlation coefficient r ⫽ 0.70;
P ⬍ 0.0001) and a moderate correlation between the within the first 48 h after surgical intervention and then
LBP concentration and the WBC count (r ⫽ 0.33; P ⬍ decreased continuously toward reference values. WBC
0.001). We found weak correlations between the CRP counts persisted within the upper portion of the refer-
concentration and the WBC count (r ⫽ 0.26; P ⬍ 0.05). ence interval during the entire IE episode, except for
No correlations between the 3 variables were found in surgical intervention, which caused a moderate in-
the HVD patients or the healthy blood donors. crease. This profile is typical and has been observed in
Fig. 2A presents an example of the progression in most analyzed episodes of uncomplicated IE. Fig. 2B
LBP and CRP concentrations and the WBC count dur- summarizes the progression in LBP and CRP concen-
ing an uncomplicated episode of IE. The temporal pro- trations and the WBC count in a patient with a notice-
gression in the concentration of LBP strictly followed ably low LBP response and typical progression in the
that of CRP. Both LBP and CRP showed increased con- CRP concentration and the WBC count during an un-
centrations upon hospital admission and a prompt de- complicated IE episode. Even surgical intervention
crease after the administration of adequate antibiotic caused only a 2-fold increase in the LBP concentration.
treatment. CRP and LBP concentrations increased Fig. 2C summarizes the progression in a case of a com-

Clinical Chemistry 55:2 (2009) 297

 Fig. 1. Serum LBP and CRP concentrations and the WBC count in IE patients, patients with HVDs, and healthy blood
donor controls.
Serum LBP concentrations (A), serum CRP concentrations (B), and the WBC count (C) in IE patients (n ⫽ 60), HVD patients (n ⫽
40), and healthy control individuals (n ⫽ 55). Scatter plots show the distributions of values for the 3 markers in the 3 groups
(***P ⬍ 0.0001, IE patients vs HVD patients and vs healthy controls, HVD patients vs healthy controls; **P ⬍ 0.001, HVD
patients vs healthy controls). Insets display the distributions of values for the 3 markers according to the length of empirical
antibiotic treatment of IE patients. Solid horizontal lines represent mean values; dotted horizontal lines represent reference values.

298 Clinical Chemistry 55:2 (2009)

LBP in Infectious Endocarditis

Fig. 2. Different progressions of LBP and CRP concentrations and the WBC count during 3 IE episodes.
Examples of the progression of LBP and CRP concentrations and the WBC count during an uncomplicated IE episode (A), a
noticeably low LBP response during an IE episode (B), and a complicated IE course with recurrent infectious episodes (C). Arrows
indicate the onset of the LBP concentration increase compared with the CRP concentration. X, initiation of antibiotic treatment;
S, surgical intervention.

Clinical Chemistry 55:2 (2009) 299

 Fig. 3. Comparison of LBP and CRP concentrations and the WBC count in IE patients and HVD patients before and
during the 5-day follow-up after surgical intervention.
Progression of LBP and CRP concentrations and the WBC count in IE patients (䡺, n ⫽ 23) and HVD patients (f, n ⫽ 21). Data
are presented as the mean and SD values for LBP (A) and CRP (B) concentrations and the WBC count (C) immediately before
surgical intervention and their progression during the 5 days after surgical intervention. Dotted horizontal lines indicate
reference values for each variable. ***P ⬍ 0.0001; **P ⬍ 0.001; *P ⬍ 0.05.

300 Clinical Chemistry 55:2 (2009)

LBP in Infectious Endocarditis
plicated IE course. The patient experienced 28 days of
recurrent infectious episodes while receiving antibiotic
treatment. LBP and CRP concentrations showed re-
lated progression patterns; however, postoperative in-
creases in LBP values occurred 3 days earlier than the
increases in CRP concentrations. A similar progression
pattern was observed in 2 other cases with recurrent
infectious episodes (data not shown). WBC counts
were increased considerably compared with an un-
complicated IE course.
The progression in LBP and CRP concentrations
and the WBC count was measured before and within 5
days after surgical intervention in 29 IE patients and 21
HVD patients. At the time of surgery, LBP and CRP
concentrations were within the reference interval in 5
IE patients and 2 IE patients, respectively, and the WBC
count was within the reference interval in 14 IE pa-
tients. LBP and CRP concentrations and the WBC
count were within their respective reference intervals
for all HVD patients. Preoperative LBP and CRP con-
centrations remained significantly higher in IE patients
than in HVD patients (P ⬍ 0.0001; Fig. 3, A and B).
Similarly, the preoperative WBC count was higher in IE
patients than in HVD patients (P ⬍ 0.001, Fig. 3C);
however, more than half of the evaluated IE patients
had WBC counts within the upper portion of the ref-
erence interval. Peak LBP concentrations were ob-
served 24 – 48 h after surgical intervention [34.64
(12.85) mg/L in IE patients vs 33.90 (10.12) mg/L in
HVD patients, Fig. 3A]. Peak CRP concentrations were
also observed during this period [179.40 (59.84) mg/L
in IE patients vs 177.40 (50.82) mg/L in HVD patients,
Fig. 3B]. In contrast, peak WBC counts were observed
0 –12 h after surgical intervention. We no longer ob-
served a statistically significant difference between IE
patients and HVD patients in LBP values, whereas
these 2 patient groups showed statistically significant
differences in the CRP concentration and the WBC
count up to 12 h after surgical intervention (see Fig. 3,
B and C).
Discussion
Several studies have reported increased LBP serum
concentrations in patients with severe sepsis due to
gram-positive, gram-negative, and fungal infections
(19, 20 ). IE is a bacterial infection comparable to sep-
sis, but infection of the endocardium usually is associ-
ated with a low-level and noncontinuous bacteremia, a
situation that contrasts with that of sepsis. To date, the
CRP concentration and the WBC count have com-
monly been used for IE diagnosis and monitoring a
patient’s response to therapy. No systematic data have
previously been published on the progression of serum
LBP concentrations in IE or the potential of LBP as a
diagnostic marker for this disease.
In this study, we evaluated the clinical applicability
of LBP as a supportive biomarker for IE diagnosis and
monitoring disease progression and compared the re-
sults with those obtained for CRP and the WBC count.
LBP and CRP values were significantly higher in IE
patients upon their admission to the hospital than in
the HVD patients and the healthy controls (Fig. 1, A
and B). Mean LBP concentrations decreased with pre-
vious antibiotic treatment, with a notable decrease ap-
parent after 10 days of antibiotic treatment, although
comparatively high concentrations were still observed
in some patients after 21–30 days of antibiotic treat-
ment. The patients with the higher LBP concentrations
during this later time interval experienced IE episodes
with major complications and severe bacteremia. This
observation leads to the assumption that the occur-
rence of high LBP concentrations after prolonged an-
tibiotic treatment may be correlated with a compli-
cated disease progression; however, because our study
cohort included only 15 patients with long-term anti-
biotic treatment (⬎20 days), this hypothesis will have
to be validated with a larger group of patients to ex-
clude the possibility that these observations are merely
random outliers. We did not observe a statistically sig-
nificant difference in LBP values linked to the causative
pathogen (data not shown); however, the pathogen
species and the access of antibiotics to the infected area
of the heart valve still influence the effectiveness of
antibiotic treatment and thus the reduction in the in-
flammatory trigger. We are aware of only one other
published study regarding the value of serum LBP
measurements at hospital admission for the diagnosis
of IE, and the results of that study contradict those of
our study (12 ). Watkin et al. (12 ) observed that se-
rum LBP concentrations were slightly but not signifi-
cantly higher in IE patients than in controls. The
mean LBP concentration was noticeably higher in the
Watkin et al. control group, with a broader range
(mean, 15.76 mg/L; range, 8.97–30.73 mg/L), than in
our control group (mean, 5.62 mg/L; range, 3.50 –
8.90 mg/L). One possible explanation for these diver-
gent results is that the study of Watkin et al. and our
study used different LBP assays.
We found the diagnostic sensitivities and specific-
ities of both LBP and CRP to be high (⬎90%). The
WBC count had a low diagnostic sensitivity (26.7%)
but a high diagnostic specificity (100%). All of the ex-
amined markers had nearly equivalent high positive
predictive values. The WBC count had the lowest neg-
ative predictive value (67.9%), whereas LBP and CRP
had equivalent high negative predictive values (97.8%
and 96.8%, respectively). In short, serum LBP and CRP
concentrations were the most sensitive laboratory vari-
Clinical Chemistry 55:2 (2009) 301
ables for the detection of bacterial infection in IE pa-
tients and had comparable diagnostic sensitivities and
specificities. The use of LBP and CRP markers sepa-
rately or in combination does not alter their diagnostic
effectiveness. Remarkably, the concentrations of both
LBP and CRP were within their reference intervals in 2
IE episodes. This finding reflects a serious limitation
and suggests that neither the LBP concentration nor
the CRP concentration should be used to rule out IE.
Therefore, it is of major importance to consider the
complete clinical presentation, including echocardio-
graphic findings and blood-culture results.
The applicability of LBP for monitoring the re-
sponse to antibiotic therapy was determined by means
of serial LBP measurements. Antibiotic treatment in-
fluenced LBP and CRP values substantially, whereas
antibiotic treatment influenced the WBC count only in
complicated IE courses. The progression in the con-
centration of LBP in our patients corresponded very
closely with that of CRP, and the high correlation ob-
served between LBP and CRP strongly suggests a com-
mon origin of stimulation. This supposition leads to
the inevitable question: Why implement a new marker
for clinical use if its characteristics are very similar to
those of an established marker? Certainly, we recog-
nized a distinction between LBP and CRP in compli-
cated IE courses, in which the LBP concentration was
more likely to increase earlier in cases of reinfection.
The profile shown for a complicated course (Fig. 2C)
was observed in 2 other cases with multiple periods of
infection. In this context, serial measurements of both
LBP and standard laboratory variables may allow ear-
lier recognition of a new local septic crisis. Addition-
ally, an increased CRP concentration is also strongly
associated with rheumatic disorders (17 ), and in such
cases the potential of CRP to distinguish between bac-
terial and viral infection is low (18 ). There have been 2
studies regarding the clinical value of LBP in this con-
text. Kaden et al. observed that cytomegalovirus infec-
tion is not associated with increased LBP concentra-
tions (21 ), and Heumann and coworkers noted
increased LBP concentrations in patients with rheu-
matic disorders (28 ). By comparison, the percent in-
creases in LBP concentrations calculated for patients
with rheumatic disorders (degenerative arthritis, 6.3%;
rheumatoid arthritis, 25.8%; reactive arthritis, 46.0%)
were lower than the 83.2% increase seen in our IE co-
hort. These preliminary results support the hypothesis
of an increased specificity of LBP for the detection of
bacterial infection in the evaluation of inflammatory
processes and a potential for distinguishing between
bacterial and nonbacterial infections.
We examined the influence of cardiac surgery on
LBP concentrations in IE and HVD patients to evaluate
the effect of surgery on the diagnostic specificity and
302 Clinical Chemistry 55:2 (2009)
sensitivity of LBP and its utility in monitoring disease
progression. The inflammatory response caused by
cardiac surgery is due to several stimuli, including ex-
posure of the blood to nonphysiological surfaces, sur-
gical trauma, and endotoxin release (29 ). CRP is
strongly affected by surgical intervention within the
first 24 h, independently of any existing bacteremia.
A similar influence on the progression of the LBP
concentration has been noted for abdominal surgery,
although only a few studies have reported LBP con-
centrations in patients who have undergone cardio-
vascular interventions (30, 31 ). Consequently, we in-
vestigated the influence of cardiac surgery on LBP
values and whether they were less influenced by cardiac
surgery than CRP or WBC values. We expected post-
operative LBP concentrations to be significantly in-
creased within the first 24 h in IE patients compared
with HVD patients because of an increased distribu-
tion of LPS or other bacterial components as a conse-
quence of the infected valve. In our study, the serum
concentrations of LBP and CRP were considerably in-
creased in both groups within the first 24 –72 h after
surgical intervention, and no reduced influence of
surgery on LBP was seen. In addition, we observed no
difference between IE patients and HVD patients in the
courses of LBP concentrations following surgical inter-
vention. Nevertheless, the heterogeneity in biomarker
concentrations is remarkably high, especially for LBP
and CRP. Given individual differences in inflamma-
tory responses in general, the different severities of in-
fections, and the different stages of antibiotic treatment
in IE patients, the averaging of biomarker time courses
may not be sufficient to recognize trends in marker
progression. The averaging of measurements of clinical
markers in larger patient cohorts often obscures partic-
ular case effects that could provide additional impor-
tant information. Thus, it is of major importance to
base decisions in particular cases on the progression of
the individual biomarkers. The specificities and sensi-
tivities for LBP and CRP were determined before sur-
gical intervention, and their concentrations are likely
to be higher if patients have undergone surgery, be-
cause of the additional stimulation of the inflammatory
response. In contrast, the use of LBP and CRP values
for monitoring disease progression is not limited by the
time of surgery.
Our study has some limitations. IE is a relatively
infrequent disease, and the availability of a large num-
ber of patients in an appropriate time frame is limited.
Although the sizes of the IE and HVD cohorts of pa-
tients available for measuring progression were rela-
tively small, the power of the present study was suffi-
cient to show the value of serial LBP measurement for
monitoring antibiotic therapy. We consciously chose
the HVD and healthy control groups to exclude any
LBP in Infectious Endocarditis

influences on LBP caused by HVDs or LBP fluctuations
in healthy individuals; however, the typical clinical sit-
uation in the diagnosis of IE is a patient with prolonged
fever and other nonspecific complaints. In a follow-up
clinical study, a cohort of other patients with fever
would be an ideal control group and would provide
additional data regarding the sensitivity and specificity
of LBP for evaluating fever. Also beneficial would be
adequate patient cohorts for evaluating LBP for distin-
guishing between bacterial infection, viral infection,
and general inflammatory responses. Another general
problem is the heterogeneity of the IE patient cohort.
Patients exhibit different infection severities, show in-
dividual inflammatory responses, and may be at differ-
ent stages of antibiotic treatment. Hence, test results
primarily depend on the patient population and pretest
probabilities. The advantages of LBP in cases of rein-
fection or a complicated disease progression require
validation with a larger group of IE patients.
The data of our study demonstrated that LBP is
strongly correlated with CRP and appears to be a useful
tool for the diagnosis of IE and following the response
of the disease to therapy; however, we have found no
significant benefit that would legitimize the standard
use of LBP as a marker instead of CRP. The value of
LBP as a marker for early recognition of a new local
septic crisis that we have highlighted has to be thor-
oughly established in further investigations. Neverthe-
less, we propose the use of LBP as a marker in addition
to CRP for the diagnosis of IE and for monitoring the
response to therapy, particularly in cases with recur-
rent infection.
Author Contributions: All authors confirmed they have contributed to
the intellectual content of this paper and have met the following 3 re-
quirements: (a) significant contributions to the conception and design,
acquisition of data, or analysis and interpretation of data; (b) drafting
or revising the article for intellectual content; and (c) final approval of
the published article.
Authors’ Disclosures of Potential Conflicts of Interest: No authors
declared any potential conflicts of interest.
Role of Sponsor: The funding organizations played no role in the
design of study, choice of enrolled patients, review and interpretation
of data, or preparation or approval of manuscript.
Acknowledgments: We thank Sarah Kirkby for her linguistic advice
and Doris Hendig for helpful discussions.

1. Naber CK, Bauhofer A, Block M, Buerke M, Erbel
R, Graninger W, Herrmann M. S2-Leitlinie zur
Diagnostik und Therapie der infektiösen Endokar-
ditis. Z Kardiol 2004;93:1005–21.
2. Durack DT, Lukes AS, Bright DK. New criteria for
diagnosis of infective endocarditis: utilization of
specific echocardiographic findings. Duke Endo-
carditis Service. Am J Med 1994;96:200 –9.
3. Lisby G, Gutschik E, Durack DT. Molecular meth-
ods for diagnosis of infective endocarditis. Infect
Dis Clin North Am 2002;16:393– 412.
4. Millar B, Moore J, Mallon P, Xu J, Crowe M,
McClurg R, et al. Molecular diagnosis of infective
endocarditis—a new Duke’s criterion. Scand J In-
fect Dis 2001;33:673– 80.
5. Kocazeybek B, Kücükoglu S, Öner YA. Procal-
citonin and C-reactive protein in infective
endocarditis: correlation with etiology and prog-
nosis. Chemotherapy 2003;49:76 – 84.
6. Ekdahl C, Broqvist M, Franzen S, Ljunghusen O,
Maller R, Sander B. IL-8 and tumor necrosis factor
␣ in heart valves from patients with infective
endocarditis. Scand J Infect Dis 2002;34:759 – 62.
7. Capo C, Zugun F, Stein A, Tardei G, Lepidi H,
Raoult D, Mege JL. Upregulation of tumor necro-
sis factor alpha and interleukin-1 beta in Q fever
endocarditis. Infect Immun 1996;64:1638 – 42.
8. Gouriet F, Bothelo-Nevers E, Coulibaly B, Raoult
D, Casalta JP. Evaluation of sedimentation rate,
rheumatoid factor, C-reactive protein, and tumor
necrosis factor for the diagnosis of infective en-
docarditis. Clin Vaccine Immunol 2006;13:301.
9. Alter P, Hoeschen J, Ritter M, Maisch B. Useful-
ness of cytokines interleukin-6 and interleukin-2R
concentrations in diagnosing active infective en-
docarditis involving native valves. Am J Cardiol
References
2002;89:1400 – 4.
10. Rawczynska-Englert I, Hryniewiecki T, Dzierza-
nowska D. Evaluation of serum cytokine concen-
trations in patients with infective endocarditis.
J Heart Valve Dis 2000;9:705–9.
11. Lamas CC, Eykyn SJ. Suggested modifications to
the Duke criteria for the clinical diagnosis of
native valve and prosthetic valve endocarditis:
analysis of 118 pathologically proven cases. Clin
Infect Dis 1997;25:713–9.
12. Watkin RW, Harper LV, Vernallis AB, Lang S,
Lambert PA, Ranasinghe AM, Elliott TS. Pro-
inflammatory cytokines IL6, TNF-␣, IL1␤, procal-
citonin, lipopolysaccharide binding protein and
C-reactive protein in infective endocarditis. J In-
fect 2007;55:220 –5.
13. Heiro M, Helenius H, Sundell J, Koskinen P, Eng-
blom E, Nikoskelainen J, Kotilainen P. Utility of
serum C-reactive protein in assessing the out-
come of infective endocarditis. Eur Heart J 2005;
26:1873– 81.
14. Hogevik H, Olaison L, Andersson R, Alestig K.
C-reactive protein is more sensitive than erythro-
cyte sedimentation rate for diagnosis of infective
endocarditis. Infection 1997;25:82–5.
15. Olaison L, Hogevik H, Alestig K. Fever, C-reactive
protein, and other acute-phase reactants during
treatment of infective endocarditis. Arch Intern
Med 1997;157:885–92.
16. McCartney AC, Orange GV, Pringle SD, Wills G,
Reece IJ. Serum C reactive protein in infective
endocarditis. J Clin Pathol 1988;41:44 – 8.
17. Kushner I. C-reactive protein in rheumatology.
Arthritis Rheum 1991;34:1065– 8.
18. Gendrel D, Raymond J, Coste J, Moulin F, Lorrot
M, Guerin S, et al. Comparison of procalcitonin
with C-reactive protein, interleukin 6 and inter-
feron-␣ for differentiation of bacterial vs. viral
infections. Pediatr Infect Dis J 1999;18:875– 81.
19. Blairon L, Wittebole X, Laterre PF. Lipopolysac-
charide-binding protein serum levels in patients
with severe sepsis due to gram-positive and fun-
gal infections. J Infect Dis 2003;187:287–91.
20. Opal SM, Scannon PJ, Vincent JL, White M, Car-
roll SF, Palardy JE, et al. Relationship between
plasma levels of lipopolysaccharide (LPS) and
LPS-binding protein in patients with severe sepsis
and septic shock. J Infect Dis 1999;180:1584 –9.
21. Kaden J, Zwerenz P, Lambrecht HG, Dostatni R.
Lipopolysaccharide-binding protein as a new and
reliable infection marker after kidney transplan-
tation. Transpl Int 2002;15:163–72.
22. Orlikowsky TW, Trug C, Neunhoeffer F, Deper-
schmidt M, Eichner M, Poets CF. Lipopolysaccha-
ride-binding protein in noninfected neonates and
those with suspected early-onset bacterial infec-
tion. J Perinatol 2006;26:115–9.
23. Pavcnik-Arnol M, Hojker S, Derganc M. Lipo-
polysaccharide-binding protein in critically ill
neonates and children with suspected infection:
comparison with procalcitonin, interleukin-6, and
C-reactive protein. Intensive Care Med 2004;30:
1454 – 60.
24. Schumann RR, Latz E. Lipopolysaccharide-binding
protein. Chem Immunol 2000;74:42– 60.
25. Tobias PS, Ulevitch RJ. Lipopolysaccharide bind-
ing protein and CD14 in LPS dependent macro-
phage activation. Immunobiology 1993;187:
227–32.
26. Schumann RR, Rietschel ET, Loppnow H. The role
of CD14 and lipopolysaccharide-binding protein

Clinical Chemistry 55:2 (2009) 303

 (LBP) in the activation of different cell types by
endotoxin. Med Microbiol Immunol 1994;183:
279 –97.
27. Dreier J, Szabados F, von Herbay A, Kröger T,
Kleesiek K. Tropheryma whipplei infection of an
acellular porcine heart valve bioprosthesis in a
patient who did not have intestinal Whipple’s
disease. J Clin Microbiol 2004;42:4487–93.
28. Heumann D, Bas S, Gallay P, Le Roy D, Barras C,
Mensi N, et al. Lipopolysaccharide binding pro-
304 Clinical Chemistry 55:2 (2009)
tein as a marker of inflammation in synovial fluid
of patients with arthritis: correlation with inter-
leukin 6 and C-reactive protein. J Rheumatol
1995;22:1224 –9.
29. Aouifi A, Piriou V, Blanc P, Bouvier H, Bastien O,
Chiari P, et al. Effect of cardiopulmonary bypass
on serum procalcitonin and C-reactive protein
concentrations. Br J Anaesth 1999;83:602–7.
30. Fransen EJ, Maessen JG, Hermens WT, Glatz JF,
Buurman WA. Peri-operative myocardial tissue
injury and the release of inflammatory mediators
in coronary artery bypass graft patients. Cardio-
vasc Res 2000;45:853–9.
31. Sablotzki A, Börgermann J, Baulig W, Friedrich I,
Spillner J, Silber RE, Czeslick E. Lipopolysaccha-
ride-binding protein (LBP) and markers of acute-
phase response in patients with multiple organ
dysfunction syndrome (MODS) following open
heart surgery. Thorac Cardiovasc Surg 2001;49:
273– 8.