A parenterally administered anti- biotic is recommended 1 hour before the procedure. Data from a meta-analysis,22 2 case-control studies that examined purported risk factors of CIED infection,20,21 and a large, prospective, randomized, double-blinded, placebo-controlled trial strongly support the administration of antibiotic prophy- laxis for CIED implantation.89 Most experts continue to advocate a first-generation cephalosporin, such as cefazolin, for use as prophylaxis. Although not generally recommended, some advocate the use of vancomycin instead of cefazolin, particularly in centers where oxacillin resistance among staphylococci is high. If vancomycin is used, then it should be administered 90 to 120 minutes before the procedure. Van- comycin also represents an alternative to a first-generation cephalosporin in patients who are allergic to cephalosporins. In patients who are allergic to both cephalosporins and vancomycin, daptomycin and linezolid represent prophylaxis Baddour et al Cardiovascular Device Infections 467 options. Antibiotic prophylaxis is also recommended if sub- sequent invasive manipulation of the CIED is required. Preoperative antiseptic preparation of the skin of the surgical site should be done. Intraprocedurally, compulsive attention to sterile technique is mandatory. If a patient has limited subcutaneous tissue and/or poor nutrition and is at increased risk for erosion, a retropectoral pocket should be considered. In a survey of pediatric patients, 9 (13.8%) of 65 with subcutaneously placed device-pocket transvenous sys- tems developed infection compared with none of the 82 who underwent retropectorally placed systems.90 Hematoma within the pocket that complicates CIED place- ment or invasive manipulation has been identified as a risk factor associated with device placement.19 Therefore, prevention of hematoma during the procedure is desirable, and several inter- ventions have been used, although there are no data to support their use. 