Rethinking Antibiotic Prophylaxis in Femoral-Access Catheter Ablation: A Pragmatic, Risk-Based Proposal

Catheter ablation is widely performed for the treatment of supraventricular and ventricular arrhythmias; however, specific recommendations regarding antibiotic prophylaxis for femoral-access procedures are lacking in current international guidelines, resulting in substantial practice variability. Although infectious complications are rare, severe events such as infective endocarditis and septic complications have been reported and are associated with significant morbidity and mortality. At the same time, increasing concerns regarding antimicrobial resistance challenge the indiscriminate use of prophylactic antibiotics in low-risk settings, underscoring the need for a more selective and rational approach. This narrative review summarizes the available evidence on infectious complications related to femoral-access catheter ablation and electrophysiological studies. In the absence of prospective data, indirect evidence and biological plausibility were integrated to inform clinical decision-making. Based on multidisciplinary collaboration, we propose a pragmatic, risk-based institutional protocol that discourages routine prophylaxis in low-risk patients while allowing selective antibiotic use in predefined high-risk scenarios. This framework aims to balance patient safety with antimicrobial stewardship and may help reduce unwarranted variability in contemporary electrophysiology practice.