For example, there is concern about the develop- ment of antibiotic-resistant bacterial pathogens, the possibility of a fatal allergic reaction, and the costs associated with this practice, which include malpractice litigation and, additional medical and dental office visits. Since the original American Heart Association recommen- dations were made more than 50 years ago, there has been a proliferation of purported indications for the use of prophy- lactic antibiotics for patients thought to be at risk for distant site infection from invasive procedures.94 97 There is little, if any, scientific justification for administration of antibiotic prophylaxis for invasive procedures, although there is a wide range of opinions.96 A review of the literature from 1950 to 2007 for publications on cardiac electrophysiological device infections reveals more than 140 articles, none of which report hematologic infection from dental, gastrointestinal, genitourinary, dermatologic, or other procedures. The predominance of staphylococci as pathogens in CIED infections rather than oral flora98 suggests that antibiotic prophylaxis for dental procedures is of little or no value.1,89,99,100 In the rare event of a device infection due to an oral pathogen, it is most likely to have arisen from a bacteremia from a common daily event such as toothbrushing or chewing food.98 Therefore, there is currently no scientific basis for the use of prophylactic antibiotics before routine invasive dental, gastrointestinal, or genitourinary procedures to prevent CIED infection. Recommendations for Antimicrobial Prophylaxis for Invasive Procedures in Patients With CIEDs Class III 1. Antimicrobial prophylaxis is not recommended for dental or other invasive procedures not directly related to device manipulation to prevent CIED infection. 