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Coronary stent infection is a fearsome complication with high mortality rate. Since antibiotics may have only partial efficacy, invasive surgery may be needed. We present a systematic review about outcomes achieved by surgical versus medical treatment in this scenario. A literature search through Medline and Google Scholar was performed over a 30-years period according to PRISMA guidelines. Demographics, clinical data, imaging findings and treatment modalities were collected. Outcomes were analysed according to treatment. Among 1727 articles identified, after duplicate removal the title/abstract screening excluded 821 articles. After full-text screening, 31 studies were included totalling 34 patients (n 28, 82.4% male, mean age 61.7 SD +/− 10 years old). The majority of infection were sustained by S. Aureus (n 28, 82.4%), occurred within one month (median 7 days, range 1–1440) from stenting and mostly over drug-eluting stents (n21, 61.8%). The majority of patients (n30, 88.2%) underwent antibiotics at first: 12 patients (35.3%) didn't undergo additional treatment because they died, were unfit or refused major surgery or responded favorably to medical treatment; surgery was scheduled in a total of 20 patients (58.8%), as an emergent approach (n2) or after failure of antibiotics (n18). More than half of patients medically treated died (n6/11, 54.5%) versus 35% (n7/20) in surgery group. Coronary stent infections are associated with high morbi-mortality rate. Medical treatment may be the only possible approach in extremely fragile patients, however timely surgical referral is the only definitive treatment, and it is recommended whenever possible. • Coronary stent infection is a fearsome complication with high mortality rate. • Prompt and appropriate antibiotics treatment should be always initiated. • Medical treatment may be the only possible approach in extremely fragile patients. • Surgery may be very challenging, but it is recommended in most cases. • More than half of patients medically treated died versus 35% in case of surgery. [ABSTRACT FROM AUTHOR]