In patients with suspected intravenous drug use, effective long-term therapy in- cludes referral to an addiction treatment program. In a select subset of patients with a stable clinical course, it may be possible to convert from intravenous to oral antibiotics if TEE confirms the absence of paravalvu- lar extension of the infection. In addition to antibiotic therapy, early surgical intervention often (approximate- ly 50% of the time) is needed to manage infection and the sequelae of valve leaflet and paravalvular tissue de- struction (Figure 15).1,2,37 42 Recommendation-Specific Supportive Text 1. Optimal treatment of IE is based on the appropri- ately timed initiation of antimicrobial therapy that is effective against the specific infective organ- ism involved. Empirical therapy may be neces- sary in patients with septic shock or patients who show high-risk signs on presentation. Although no RCTs have been performed with regard to the use of antibiotic therapy in IE, the mortality rate before the antibiotic age neared 100%. Specific antimicrobial regimens, depending on the caus- ative microorganism, have been published by the British Society for Antimicrobial Chemotherapy and the AHA. Because there are continuous changes in antimicrobial sensitivity over time, as well as regional and site-specific differences in antimicrobial susceptibility profiles, concomitant management with the assistance of a consul- tant thoroughly familiar with these patterns is 2. Drug use associated endocarditis is associated with a significantly higher complexity of care, with increased rates of readmission, reinfection, and recurrent need for repeat interventions, and its incidence has risen 12-fold over the past decade. Addiction specialists are an important part of the Heart Valve Team for this patient pop- ulation. Addiction studies have shown that treat- ment outcomes for behavioral interventions alone for opioid use disorders are dismal, with >80% of patients returning to drug use. 