For an acute course of infection in the same setting, S aureus, S pneumoniae, and -hemolytic streptococci are more likely pathogens. Recommendations 1. For CNE, it is reasonable to obtain the proper num- ber of cultures before antibiotic drugs are begun or to stop antibiotic drugs that were started fewer than 4 days earlier (Class IIa; Level of Evidence C). 2. Infectious diseases consultation should be obtained in each case of CNE (Class I; Level of Evidence C). Complications and Surgical Issues In the current era, outpatient antibiotic therapy after initial diagnosis and stabilization is increasingly used. This makes it extremely important to define the patient population that is at higher risk for complications. Several factors predispose children with IE to potentially life-threatening complica- tions that may require early surgery. Risk factors are listed in Table 10. Other considerations that increase concern and the need for surveillance for complications include the size and location of the vegetation, acute onset of atrioventricular block, type of organism, occurrence of IE in an otherwise normal heart, and occurrence in children <2 years of age.10,11 The complications of IE can be classified into cardiac and extracardiac sequelae. Cardiac complications include congestive heart failure, new or progressive valvular dysfunction that is usually seen as increased regurgitation, periannular extension of infection, sinus of Valsalva rupture, myocardial dysfunction, obstruction of conduits or shunts, prosthetic valve dysfunction including dehiscence, pericardial effusion, and less commonly, septic emboli to the coronary arteries. Congestive heart failure is caused by various combinations of the above factors and is one of the more frequent complica- tions that carries a guarded prognosis. Progressive congestive heart failure usually is caused by worsening valvular regur- gitation, often accompanied by ventricular dysfunction. 