We analyzed 14 cases of nosocomial infective endocarditis which occurred over a seven-year period at the Beth Israel Hospital in Boston, and compared them with 90 cases of community-acquired endocarditis. Patients with nosocomial endocarditis were older, more often female, and had a greater incidence of underlying valvular heart disease and bacteremia precipitating invasive procedures (93% v 50%, P < .05). Forty-three percent of patients had infection at the site of prosthetic valves or intracardiac prosthetic material. The disease carried a significantly higher mortality than community-acquired endocarditis (43% v 11%, P < .01). The clinical presentation was acute and the infecting organisms reflected the site of origin of bacteremia, with staphylococci from skin and enterococci from urinary sources. Half of the cases in this series may have been prevented by the application of currently recommended preventive and therapeutic practices. Nosocomial endocarditis occurs in a definable sub-population of hospitalized patients and is potentially preventable.