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In recent years, the epidemiology of infective endocarditis (IE) has undergone a profound shift: intravenous drug use is no longer a marginal risk factor but a central driver of disease burden in many high-income countries. Among people who inject drugs (PWID), IE now accounts for an increasingly large proportion of cardiovascular-infectious admissions and presents with distinctive patterns of younger age, minimal structural heart disease, predominance of Staphylococcus aureus, right-sided valve involvement and frequent septic pulmonary complications.1