Pacemaker Pocket Infection: IHJ, 2025 Indian Study Reveals Incidence and Risk Factors

Cardiac implantable electronic devices (CIEDs), including permanent pacemakers, are considered lifesaving for appropriately selected patients. Due to expanding indications and increased life expectancy, more devices are being implanted in elderly patients and those with multiple comorbidities, which inherently increases their risk profile. Device-related infection remains one of the most dreaded complications, as it is associated with significant morbidity, recurrent hospitalizations, escalated healthcare costs, and even mortality. Historically, the incidence of infection rates for these devices has varied widely, ranging from 0.5% to 6% in earlier case series, underscoring the need for localized data to inform best practices. The present study aimed to specifically analyze the incidence, associated risk factors, and microbiology of PPMI within a regional context.

Study Overview

This retrospective, hospital-based observational study was conducted at a single tertiary care facility. The analysis included 802 patients who underwent CIED implantation, focusing specifically on 648 patients who received Permanent Pacemakers (PPMs). The study analyzed PPM indications, patient demographics, comorbidities, and the microbiology of any subsequent infections. Inclusion was limited to patients presenting with local inflammatory signs or purulent discharge, while patients under 18 years or those with ICD/CRT infections were excluded. Clinically, all included patients initially received intravenous Teicoplanin, followed by oral amoxicillin/clavulanic acid. When PPMI was diagnosed using standard international criteria, the standard management involved removal of the infected device and leads; once the infection was resolved, a sterilized generator was typically reimplanted contralaterally.

The Key findings from the study include:

• Among the 716 patients included in the final analysis, the incidence of PPMI was found to be 2.09% (15 patients). The majority of patients received dual-chamber devices (52.8%).

• The most frequent indication for PPM implantation was Complete Heart Block (66.2% of PPM patients).

• Notably, the infection risk was highest for devices that had been implanted more than 12 months prior (40% of all PPMI cases), indicating a substantial rate of delayed infection.

• When analyzing the 15 patients with PPMI, hypertension was the most common associated risk factor (60%), closely followed by diabetes (46.67%).

• Microbiologically, the most striking finding was the high rate of culture-negative pacemaker infections (53.33%). Among identified pathogens, methicillin-resistant Staphylococcus aureus (MRSA) dominated, accounting for 33.33% of the infections.

Clinical Relevance and Targeted Prevention

For practicing physicians, this study highlights that PPMI incidence (2.09%) aligns with global trends, but importantly, 40% of infections occurred more than a year post-implantation—underscoring the need for long-term vigilance and awareness of subclinical pocket colonization. The high proportion of culture-negative infections (53%) means clinicians should not dismiss infection when cultures are negative, especially in patients with prior antibiotic exposure or suspected fastidious organisms. MRSA emerging as the most common pathogen reinforces the dominant role of Staphylococci in device infections. Hypertension and diabetes, prevalent in the infected cohort, underscore the importance of optimizing these comorbidities before and after implantation. Overall, meticulous procedural technique, strong infection-prevention strategies, and aggressive management of risk factors remain essential to improving long-term device outcomes.

Reference: Kapoor M, Gunasekaran AK, Lyngdoh V, Kynta RL, Das PP. Incidence and risk factors of pacemaker pocket infection–an observational study. Indian Heart Journal. 2025 May 25.