Background: The referral criteria for screening echocardiography in infective endocarditis (IE) are undefined. The positive predictive value in this scenario is low and overuse of “screening’ echocardiography is potentially costly to the health system. We reviewed the appropriateness of referrals for echocardiography in the investigation of IE and the cost involved. Methods: We retrospectively reviewed all echocardiography referrals for suspected IE at Middlemore Hospital in 2012. Strongly indicated referrals were defined as: treatment for IE, Staphylococcus aureus bacteraemia or candidaemia. Results: A total of 7658 echocardiograms were performed between Jan 2012 and Dec 2012. 232 echocardiograms were performed for suspected IE. 88 (37.9%) referrals were deemed indicated; 33 (38%) patients were treated for IE. For those not treated as IE, 51 (58%) had Staphylocuccus aureus bacteraemia and 4 (4.5%) had candidaemia. Vegetation was identified in 10 (4.3%) patients. The most common alternative diagnoses were sepsis without identified focus (13%), respiratory infection (13%) and septic arthritis (10%). At a cost of NZD215.37 per echocardiogram the excess cost of echocardiograms without strong indication was NZD31013.28. Conclusions: The majority of echocardiograms referrals for suspected IE at our centre did not have strong indication, potentially generating unwarranted costs to the healthcare system. Greater efforts are needed to improve the appropriate use of echocardiography for suspected IE.