Other important issues for which early surgery is used include perivalvular extension of infection, fungal endocar- ditis, persistent bacteremia despite appropriate antibiotic therapy, unstable prosthesis, ruptured sinus of Valsalva, or ventricular septal and mycotic aneurysms.156 158 The indica- tions for surgical intervention tabulated in Table 11 should be considered recommendations of experts.17 Although the clinical circumstances seem dire, even difficult aortic root complications can be treated successfully with aortic homografts or Ross procedure autografts.159,160 Depending on the degree of valve or great vessel root damage, valve- sparing operations are often possible.110,152,161 In some Late (>1 y) prosthetic valve placement Coagulase-negative staphylococci S aureus Viridans group streptococci Enterococcus species Fungi Corynebacterium species Dog-cat exposure Bartonella species Pasteurella species Capnocytophaga species Contact with contaminated milk or infected farm animals Brucella species Coxiella burnetii Erysipelothrix species Homelessness, body lice Bartonella species AIDS Salmonella species S pneumoniae S aureus Pneumonia, meningitis S pneumoniae Solid-organ transplant S aureus Aspergillus fumigatus Enterococcus species Candida species Gastrointestinal lesions Streptococcus bovis Enterococcus species Clostridium septicum HACEK indicates Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species. Table 9. Continued Epidemiological Feature Common Microorganism(s) Table 9. Epidemiological Clues in Pathogenic Diagnosis of Culture-Negative Endocarditis Epidemiological Feature Common Microorganism(s) Injection drug use Staphylococcus aureus, including community-acquired methicillin/ oxacillin/nafcillin-resistant S aureus Coagulase-negative staphylococci -Hemolytic streptococci Fungi Aerobic Gram-negative bacilli, including Pseudomonas aeruginosa Polymicrobial Indwelling cardiovascular medical devices S aureus Coagulase-negative staphylococci Fungi Aerobic Gram-negative bacilli Corynebacterium spp Genitourinary disorders, infection, and manipulation, including pregnancy, delivery, and abortion Enterococcus species Group B streptococci (Streptococcus agalactiae) Listeria monocytogenes Aerobic Gram-negative bacilli Neisseria gonorrhoeae Chronic skin disorders, including recurrent infections S aureus -Hemolytic streptococci Poor dental health, dental procedures Viridans group streptococci Nutritionally variant streptococci Abiotrophia defectiva Granulicatella species Gemella species HACEK organisms Alcoholism, cirrhosis Bartonella species Aeromonas species Listeria species Streptococcus pneumoniae -Hemolytic streptococci Burn patients S aureus Aerobic Gram-negative bacilli, including P aeruginosa Fungi Diabetes mellitus S aureus -Hemolytic streptococci S pneumoniae Early ( 1 y) prosthetic valve placement Coagulase-negative staphylococci S aureus Aerobic Gram-negative bacilli Fungi Corynebacterium species Legionella species (Continued) Baltimore et al Infective Endocarditis in Childhood: 2015 Update 1509 circumstances, cardiological evaluation may suggest a need for early surgical therapy, performed even before steriliza- tion of blood. 