Infection Prevention and Device Pocket Management in Cardiac Implantable Electronic Devices: Emerging Strategies

Cardiac implantable electronic device (CIED) infection remains one of the most serious complications of device therapy, causing significant morbidity, mortality, healthcare utilization, and costs. Despite advances in device technology and preventive strategies, infection rates have not declined and may be increasing. This review summarizes current evidence on CIED infection prevention and device pocket management, with a focus on risk-based prevention, procedural strategies, and emerging technologies.

Increasing evidence supports individualized infection-prevention strategies based on patient-, procedure-, and device-related risk factors. Contemporary approaches extend beyond peri-procedural antibiotic prophylaxis and include structured risk stratification, optimization of modifiable risk factors, meticulous pocket management, prevention of pocket hematoma formation, taurolidine containing adjuncts and selective use of antibacterial technologies such as absorbable antibiotic envelopes. Novel device platforms including leadless pacemakers, subcutaneous and extravascular implantable cardioverter-defibrillators, and conduction system pacing may further reduce infectious burden in selected patients. Emerging technologies including antimicrobial biomaterials, artificial intelligence-assisted risk prediction, and digital wound surveillance may facilitate precision-based infection prevention. CIED infection prevention increasingly requires a comprehensive and individualized approach that addresses the entire contamination - biofilm - infection pathway. Contemporary prevention strategies integrate patient optimization, procedural excellence, pocket management, and selective use of adjunctive technologies. Future advances are likely to shift infection prevention toward precision-based interventions tailored to individual patient risk profiles and device requirements.