Patients with right-sided, catheter-related intravascular infection may have few or no specific cardiovascular signs or may present with asthma-like symptoms or signs related to septic pulmonary embolization As described above, an increase in the population of chil- dren requiring a long-term central venous catheter (CVC) and of those with complex congenital heart defects and correspondingly complex surgical interventions requiring prosthetic materials has changed the epidemiology and micro- biology of IE and impacted the diagnostic approach. Duke Criteria The modifications of the Duke criteria for diagnosis of IE74 76 have been demonstrated to be helpful in diagnosing IE in chil- dren, although the number of patients in these studies has been small, and there have been questions of specificity (Tables 3 The presence of a CVC may prolong a bacteremic state, thus requiring the removal of the CVC before criteria The incorporation into the modified Duke criteria of new molecular diagnostic methods on surgical specimens (eg, polymerase chain reaction [PCR]) has been proposed to help identify organisms in culture-negative IE.80 Although the revised Duke criteria have been validated for the diagno- sis of IE in children,9 the emergence of S aureus as the most common pathogenesis has important implications. The Duke criteria identify S aureus bacteremia as a major criterion, regardless of whether the infection was nosocomial or com- munity acquired or whether a primary source of infection was present or absent.75 suggests that the presence of a CVC may skew the diagnosis of IE, because the attempt to salvage the catheter rather than remove it serves to prolong the bacteremic state and raises the question of whether S aureus bacteremia should be regarded as a major microbiological cri- teria only if cultures remain positive after removal of the CVC. 