Cardiovascular implantable electronic device infections requiring extraction: A national analysis of contemporary trends, clinical predictors, and economic burden, 2016–2022

BACKGROUND Cardiovascular implantable electronic device (CIED) infections are characterized by substantial morbidity, mortality, and economic burden. Contemporary national data analysis stratifying CIED infections by reimplantation strategy is limited. OBJECTIVES To characterize incidence, patient and hospital predictors, microbiology, in-hospital mortality, and costs of CIED infections requiring device removal stratified by same-admission reimplantation versus those without same-admission reimplantation. METHODS Using the National Inpatient Sample, adult U.S. hospitalizations (2016-2022) with CIED-related infection requiring device removal were identified with ICD-10-CM/PCS codes. Hospitalizations were classified as CIED infection with same-admission reimplantation or CIED infection without same-admission reimplantation. Survey-weighted analyses estimated national incidence, temporal trends, and inflation-adjusted hospitalization costs. Multivariable survey-logistic regression identified predictors of infection and in-hospital mortality and evaluated organism-specific mortality among cases with coded pathogens. RESULTS Among approximately 1.2 million CIED implantation hospitalizations, 58,880 involved CIED infection requiring device removal (annual rate 0.024%; p for trend = 0.237). Same-admission reimplantation accounted for 31.2% of infections and declined over time, while hospitalizations without same-admission reimplantation increased to 71.4% (both p for trend = 0.0006). Congestive heart failure, atrial fibrillation, autoimmune disease, malnutrition, obesity, and peripheral arterial disease were independently associated with infection, whereas female sex was protective. Staphylococcal species were coded in 38.8% of infections; methicillin-resistant Staphylococcus aureus (MRSA) nearly doubled in-hospital mortality, whereas methicillin-susceptible S. aureus (MSSA) was not independently associated with excess adjusted mortality. Adjusted in-hospital mortality for CIED infection hospitalizations increased from 4.6% to 6.0%, and inflation-adjusted mean costs for infection admissions had increased by 28.5%. CONCLUSION In this contemporary, nationally representative ICD-10 era cohort, the CIED infection rate requiring extraction remained low and stable at 0.024%, yet these events carried outsized clinical and economic consequences. Nearly 70% of infections were managed without same-admission reimplantation and occurred predominantly in patients with substantial multimorbidity, delineating a large, previously underrecognized population. MRSA infections nearly doubled in-hospital mortality, whereas MSSA, despite being more prevalent, was not independently associated with excess adjusted mortality. Infection-related hospitalization costs increased by almost 30% and rose 1.6-fold faster than costs for uncomplicated CIED implantations, indicating that CIED infections consume a disproportionate and accelerating share of healthcare resources.