In a recent 15-year review of children treated for IE at the Texas Heart Institute in Houston, TX, early surgery was performed in 61% of patients, with most of these surgeries occurring within 7 days and half within 3 days of diagnosis.16 Several other studies have also shown that early surgery can be performed with low morbidity and mortality in childhood and improves the overall outcome Recent observational studies in adults have suggested that when adjusted for both selection and survi- vor biases, surgery in patients with left-sided IE, even when not considered urgent, may produce better outcomes and lower mortality than medical therapy alone.162,163 Although these data have not been replicated in specific pediatric- focused studies, the information does provide a reason- able framework for similar consideration in pediatric IE. Similarly, in prosthetic valve endocarditis, data from series in adults indicate that even aside from obvious indications for early surgery such as symptomatic heart failure, valve dehiscence, and great vessel root abscess formation, among others, surgery may benefit patients with relapsing pros- thetic valve endocarditis even if valvar function remains intact after prolonged medical therapy. Recommendations 1. Prophylactic surgery to prevent a primary embolic event is not recommended given the lack of proven benefit and long-term risks of valve replacement in childhood (Class III; Level of Evidence C). 2. Surgery may be considered for patients with relaps- ing prosthetic valve endocarditis even if valvar func- tion remains intact after prolonged medical therapy (Class IIb; Level of Evidence B). Prevention of Endocarditis For >5 decades, scientific organizations and public health- care policy groups around the world have advocated for the administration of antibiotic drugs for prophylaxis against IE. 