Infection of Cardiac Implantable Electronic Devices in Low and Middle Income Countries: A Systematic Review

Cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices, are increasingly used in low- and middle-income countries (LMICs). However, device-related infections remain a significant complication, leading to increased morbidity, mortality, and healthcare burden. Evidence from LMICs is limited and fragmented.

To systematically review the incidence, microbiological profile, management strategies, and clinical outcomes of CIED-related infections in LMICs.

A comprehensive literature search was conducted across PubMed and Google Scholar up to September 2025. Studies from LMICs reporting on CIED-related infections were included. Data on infection rates, device types, reuse practices, microbiology, and outcomes were extracted and synthesized.

Fifty-five studies encompassing 96 448 CIED recipients were included. A total of 1910 infected patients were analyzed, yielding an overall infection rate of 1.65%. Infection rates ensuing reused CIED implantation (1.82%) are not consistently higher than those reported for new devices. Infection risk was higher with complex devices-5.9% in CRTs and 4.74% in ICDs-compared to 1.75% in pacemakers. Replacement and revision procedures had significantly higher infection rates (2.1%) than de novo implantations (0.57%). Among 1063 infections with available microbiological data, coagulase-negative Staphylococci (26.0%) and Staphylococcus aureus (25.4%) were predominant, though 35.4% were culture-negative. Device extraction was performed in 75% of treated patients. Infection-related mortality was 8.87%, and long-term follow-up data were limited.

CIED infections in LMICs occur at higher rates than in high-income settings, particularly with complex devices and reinterventions. Culture-negative infections are common, and access to guideline-recommended care, including device extraction, is often limited.