Chlorhexidine vs Povidone-Iodine Alcohol Solutions for Cardiac Implantable Electronic Devices: A Prospective Randomized Study.

Summary

In a multicenter randomized trial of 2,272 patients undergoing CRT and other CIED procedures, alcoholic chlorhexidine did not significantly reduce device-related infections compared with alcoholic povidone-iodine over 24 months. Major cardiovascular events and local noninfectious side effects were similar between groups.

Key Findings

• Device-related infections: 2.9% with alcoholic chlorhexidine vs 3.9% with alcoholic povidone-iodine (adjusted subhazard ratio 0.75; 95% CI 0.48–1.20; P=0.23).
• Major cardiovascular events were similar (31.5% vs 31.3%; subhazard ratio 1.01; 95% CI 0.87–1.17).
• Noninfectious local side effects occurred at comparable rates (12.9% vs 13.3%).
• Large sample size (N=2,272), median age 72 years, 75.1% men; outcomes adjudicated blinded.

Clinical Implications

Either alcoholic chlorhexidine or alcoholic povidone-iodine can be used for skin antisepsis in CRT/CIED implantations, shifting focus toward comprehensive infection-prevention bundles and risk stratification rather than antiseptic selection alone.

Limitations

• Open-label design may introduce performance bias despite blinded outcome adjudication.
• Event rates were low; the trial may be underpowered to detect small differences between antiseptics.

Future Directions

Evaluate bundled infection-prevention strategies, high-risk subgroups, cost-effectiveness, and alternative concentrations/formulations in adequately powered trials.