In these children, infection caused by Streptococcus pneumoniae or S aureus is likely. The clinical findings of IE in children relate to 4 underly- ing phenomena: bacteremia (or fungemia), valvulitis, immuno- logic responses, and emboli. Valvulitis may result in changing cardiac auscultatory findings or the development of congestive heart failure. Extracardiac manifestations of IE (eg, petechiae, hemorrhages, Roth s spots, Janeway lesions, Osler nodes, or splenomegaly) are considerably less common in children than in adults. Renal abnormalities (eg, glomerulonephritis, infarct) can result from an embolic or immune complex mediated pro- cess. Emboli to the abdominal viscera, the brain, or the heart are common (especially noted in the adult literature) and may produce symptoms associated with ischemia, hemorrhage, or both. In rare cases, central nervous system mycotic aneurysms can occur; their rupture can be catastrophic. The cardiac examination in the child with IE is highly variable and depends on the type of heart disease present and the particular site of infection. Valvular lesions that produce leaflet destruction result in regurgitant murmurs. In children with cyanotic CHD who have undergone systemic-pulmonary artery shunt procedures, however, the murmur may not change. Rather, declining systemic oxygen saturation may reflect graft infection with obstruction of flow. 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. 