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.