Cardiac implantable electronic device infections: Emerging paradigms in precision prevention and personalized management.

Abstract

Cardiac implantable electronic device (CIED) infections remain a major source of morbidity, mortality, and healthcare expenditure despite continuing advances in device technology. Increasing procedural complexity, repeat interventions, and an aging population with multiple comorbidities have shifted the focus from treatment alone toward comprehensive infection prevention. Biofilm formation is now recognized as the central pathogenic mechanism underlying CIED infection, explaining both the limited efficacy of antimicrobial therapy in the presence of retained hardware and the need for complete system extraction in established infection. This narrative review summarizes contemporary evidence supporting a multimodal approach to CIED infection prevention and personalized management. Prevention extends beyond perioperative antibiotic prophylaxis and skin antisepsis to encompass structured patient optimization, procedural contamination control, hematoma prevention, targeted Staphylococcus aureus decolonization, antibacterial envelopes, taurolidine-based pocket antisepsis, emerging antibiofilm technologies, and novel device platforms such as leadless pacemakers and extravascular implantable cardioverter-defibrillators. Risk stratification using PADIT, BLISTER, and complementary prediction models enables individualized allocation of preventive interventions according to estimated infection risk rather than uniform prophylaxis. Advances in diagnosis now combine multimodality imaging with biofilm-oriented microbiology, including device sonication, molecular diagnostics, and metagenomic sequencing, supporting pathogen-directed antimicrobial therapy and individualized clinical decision-making. Contemporary management likewise requires multidisciplinary expertise integrating extraction-risk assessment, complete hardware removal when indicated, optimized antimicrobial stewardship, and carefully planned reimplantation strategies. Rather than using the term precision medicine in its traditional genomic sense, this review emphasizes precision prevention and personalized management, whereby preventive and therapeutic interventions are tailored to each patient's quantified infection risk by integrating procedural, microbiological, host-related, and biofilm-associated determinants. Future improvements in clinical outcomes will depend on implementing integrated, risk-guided prevention strategies supported by multidisciplinary expert teams and emerging diagnostic and preventive technologies.