Infective endocarditis (IE) is a notorious complication of intravenous drug use (IDU). It typically affects the cardiac valves. Among these, the tricuspid is the most common affected valve, although the mitral and/or aortic valves can also be involved. Methicillin sensitive staphylococcus aureus (MSSA) is the most common etiological microbial agent of IE in IDU. Once IE is diagnosed, antibiotic treatment should start immediately after blood cultures have been obtained. However, IE in this particular patient population is more difficult to treat, and has a high recurrence rate compared to other patient populations, because of continuing IDU and medical non-compliance. Here, we present an interesting case of IE in a relatively young IDU patient with severe MSSA positive sepsis. The updated diagnostic and treatment strategies, as well as the ethical issues involved in the management of IE patients in the setting of current active IDU will also be discussed.