Bacterial endocarditis occurs in children with congenital heart disease or central venous catheters or in adolescents, who use intravenous drugs. Seeding can occur via dental caries, skin infections, and manipulation of the airway, gastrointestinal tract, or genitourinary tract. Staphylococcal and streptococcal species predominate, with HACEK organisms (Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella) and Candida as occasional offenders. Diagnosis is suspected in the at-risk patient in the presence of unexplained fever, weakness, myalgia, and arthralgia. A new murmur is present in fewer than 50% of cases. Other findings may include congestive heart failure secondary to valvular insufficiency, petechiae, or new neurologic findings. Adult cutaneous hallmarks such as Janeway lesions or Osler nodes are rare. Blood culture will identify the organism in 90% of cases. Other supportive data include elevated acute-phase reactants such as white blood cell count or erythrocyte sedimentation rate, anemia, hematuria, or embolic infiltrates. The echocardiogram has a 70% to 80% detection rate, with failure occurring in children who have complex congenital heart disease.