Infective endocarditis (IE) is a potentially fatal disease. Even with appropriate antimicrobial treatment, mortality rates range from 10% to 25% [1]; therefore, prevention of disease is very important. Guidelines have been created to estimate which patients with certain risk factors would most benefit from IE prophylaxis. However, there have been no controlled, clinical trials to demonstrate the protective efficacy of antibiotic regimens in the prophylaxis of IE in humans. Such trials will not likely ever be done for two major reasons: From a study-design perspective, the relative rarity of IE developing after a single transient bacteremic episode would require > 6,000 patients, all with predisposing cardiac disease [2]. Secondly, such a study would also be considered unethical. Therefore, the guidelines that have been devised have been based on the efficacy of IE prophylaxis in animal models, previous antimicrobial susceptibility testing data of the most likely pathogens, pharmacokinetic studies, and studies on the incidence and prophylaxis of procedure-related bacteremias. Thus, the evidence for these recommendations is at the level of expert opinion, the efficacy is not 100%, and the changing microbiology of IE may necessitate updated new recommendations.

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