Predictors of cardiac device infection regardless of antibacterial envelope usage: insights from a large real-world cohort

Introduction

Cardiac implantable electronic device (CIED) infection remains a major cause of morbidity, rehospitalization, and healthcare burden. Identifying clinical and procedural predictors of infection is essential to guide prevention strategies in high-risk recipients.

Methods

We retrospectively analyzed 1,699 consecutive patients who underwent ICD or CRT-D implantation, replacement, or revision between 2017 and 2024.

Among them, 1,211 (71%) received no envelope, 241 (14%) Tirex, and 247 (15%) Tauropace.

Baseline clinical and procedural characteristics, comorbidities, and medical therapy were collected.

Independent predictors of CIED-related infection were identified using multivariable logistic regression including demographic, procedural, and clinical variables.

Results

The mean age was 71 ± 11 years, 75% were male, and 22% underwent CRT-D implantation. Diabetes and chronic kidney disease were present in 56% and 47% of patients, respectively.

Overall, infection occurred in 29 patients (1.7%).

Compared with non-infected patients, those with infection more frequently received a CRT-D system and had longer procedures.

At multivariable analysis, CRT-D device (OR 4.00, 95% CI 1.31–12.28, p = 0.015) and procedure duration (OR 1.02 per minute, 95% CI 1.01–1.04, p = 0.008) were independent predictors of infection.

Age, sex, ejection fraction, diabetes, renal dysfunction, and antithrombotic therapy were not significantly associated with infection risk.

Conclusions

In this large real-world cohort of high-risk CIED recipients, procedural complexity—specifically CRT-D implantation and longer implant duration—emerged as the strongest independent predictors of infection.

These findings highlight the central role of procedural optimization and meticulous aseptic technique to minimize CIED-related infections, regardless of envelope use.