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

BACKGROUND: 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. OBJECTIVE: To systematically review the incidence, microbiological profile, management strategies, and clinical outcomes of CIED-related infections in LMICs. METHODS: 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. RESULTS: 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. CONCLUSION: 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.