endocarditis; broad range bacterial 16S rDNA and fungal 18S rDNA PCR; early surgery; infective endocarditis prophylaxis downgrade; endocarditis team Infective endocarditis (IE) is an infection of the endocardium, valves, or related structures of the heart and walls It may arise following more frequent and prolonged bacteremia in a patient with or without a predisposing cardiac lesion Infective endarteritis is a similar process It may involve patent ductus arteriosus, shunts (native and constructed), aneurysms, stretching devices (stents), collateral closing devices, neonatal umbilical lines, and damaged arterial walls The term infective endarteritis is now avoided, and all of these are united under IE Despite advances in diagnosis and treatment, IE of the 21st century may still be a life-threatening disease with significant mortality and morbidity Pediatric IE has a lower incidence and better outcomes than IE in adults The predisposing factors for IE in high-income countries have changed: although rheumatic heart disease–related IE has dramatically declined, there is a rise of the congenital heart disease (CHD)-related, postprocedural, and device-related pediatric IE The mainstay of management of IE is the multidisciplinary approach coordinated by the endocarditis team: cardiologist, clinical microbiologist/infectious diseases specialist, and cardiothoracic surgeon All information is outlined in detail in the guidelines, recommendations, reviews, and updates.1–15 Incidence of Pediatric Infective Endocarditis The IE incidence in children is lower than in adults and reported stable at approximately 0.43 per 100,000 children/year,16 which is far below those in adults, who have an incidence of approximately 3 to 12 per 100,000 people/year.14,17,18 A New Zealand study showed increased incidence of pediatric IE from 0.46 per 100,000/year in 1994–2002 to 0.76 per 100,000/year in 2003–2012.19 CHD-related pediatric IE is approximately 60%19 to 68%20 of the cases A large population-based 1988–2010 study on a large cohort of Canadian children with CHD reported an IE incidence of 4.1 cases/10,000 person-years,21 which is much lower than that in adults with CHD of 10.6 cases/10,000 person-years.22 However, a more recent study from Taiwan similarly reported 11.13 cases/10,000 person-years.23 The cumulative observed risk of IE is 6.1 cases/1000 CHD patients 0 to 18 years of age.21 Cyanotic CHD lesions, left-sided lesions, and atrioventricular septal defects were associated with increased risk of IE acquisition in childhood The relative risk of developing IE was substantially elevated during the 6-month postoperative period of cardiac surgery and in children younger than 3 years of age.21 There is a comparable IE frequency in boys and girls because high-risk behaviors and other lifestyle factors may be less likely to differ between boys and girls during childhood.21,24 Mortality Risk Despite significant improvements, pediatric IE remains a disease with significant mortality risk, varying from 5%24,19 to 10%25 but is much lower than in the adult IE, which is still reported at approximately 25% Pediatric IE–related mortality is much lower in native valve endocarditis 3.5% than in patients with underlying heart disease 6.7% Risk factors for mortality include some forms of CHD, premature/neonatal age, fungus, and Staphylococcus aureus as etiologic agents.24 ... people/year.14,17,18 A New Zealand study showed increased incidence of pediatric IE from 0.46 per 100,000/year in 1994–2002 to 0.76 per 100,000/year in 2003–2012.19 CHD-related pediatric IE is approximately 60%19 to 68%20 of the cases... Despite significant improvements, pediatric IE remains a disease with significant mortality risk, varying from 5%24,19 to 10%25 but is much lower than in the adult IE, which is still reported at approximately 25% Pediatric IE–related mortality is much lower in native valve endocarditis 3.5%...Incidence of Pediatric Infective Endocarditis The IE incidence in children is lower than in adults and reported stable at