INTRODUCTION
The use of cardiac implantable electronic devices (CIEDs) has
progressively increased over the past decades. This phenomenon can be
attributed to technological advancements and accumulated procedural
experience, enabling cardiac electrophysiologists to perform CIED
placements on patients with complex clinical conditions. Unfortunately,
the incidence of CIED infection is also rising, leading to increased
morbidity, mortality, and healthcare costs.(1) Infection is undeniably
the costliest device-related complication in patients receiving a
pacemaker or defibrillator.(2) The clinical benefits of complete
hardware removal are well-established in patients with CIED
infections.(3) However, wound and pocket management is an area that has
yet to receive plenty of attention. After CIED implantation, wound
healing results in fibrosis. The fibrotic avascular capsule inhibits
antibiotic penetration and normal immune mechanisms and facilitates
bacterial colonization.(4) Current guidelines recommend complete
capsulectomy based on expert opinion and limited data, with no
distinction between systemic infections (including persistent
bacteremia/infective endocarditis) and localized pocket infections.(5)
To adequately perform this procedure, significant operator experience is
required, limiting its widespread adoption.
Furthermore, performing a capsulectomy is time-consuming, requires
extensive tissue debridement, and increases the risk of bleeding and
hematoma formation, mainly in patients with chronic oral
anticoagulation.(6) Therefore, clinical practice varies widely, with
recent surveys reporting that only 58-76% of physicians perform
capsulectomy.(7,8)
Chlorhexidine is a positively charged molecule that binds to proteins
and other negatively charged molecules on the bacterial cell wall
causing instability, cellular membrane disruption, and eventually
cellular death. It is a broad-spectrum biocide with bacteriostatic and
bactericidal activity against fungi, and gram-positive and gram-negative
bacteria. It has a very efficient microbiocidal rate (nearly 100%
within 30 seconds of application) and prolonged activity due to its
ability to bind to the tissues for up to 48 hours, which is not affected
by blood or other bodily fluids.(9) These characteristics make it the
drug of choice in several clinical scenarios, including skin and mucosal
preparation for surgery, oral hygiene, prevention of
ventilation-acquired pneumonia, and infection of intravascular
catheters. Nevertheless, although preoperative chlorhexidine skin
preparation is associated with a reduced risk of CIED infection(10) and
has been suggested as a possible therapy after lead extraction,(11)
outcomes related to its use in the treatment of CIED infection have not
been described. We present the results of wound and device pocket
scrubbing with chlorhexidine as an alternative to total capsulectomy
after complete device removal in patients with CIED-related infections.