Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review

The incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery: a retrospective chart review

BACKGROUND

Shoulder instability continues to be a common problem that is difficult to treat. Part of this difficulty can be attributed to the numerous postoperative complications that can impact the clinical course. Our study aims to primarily identify the incidence of subclinical infection in patients undergoing revision shoulder stabilization surgery and secondarily identify any risk factors for developing a subclinical infection.

MATERIALS AND METHODS

From January 2012 to December 2022, 94 charts of patients who underwent revision surgery by the senior author after a previous arthroscopic or open stabilization surgery for shoulder instability were reviewed. All patients of any age who underwent either bony or soft tissue revision surgery, regardless of the number of previous surgeries or corticosteroid injections, were included. Patients were excluded if they had a previous infection in the shoulder, if there was no record of the procedures performed in the previous surgery, or if cultures were not available for review. For each patient, demographic information (age, sex, race, smoking status, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, and intravenous drug use), surgical information (procedures performed, type of surgery, and date of surgery), and culture results were recorded.

RESULTS

Overall, 107 patients were included in our study. Twenty-nine patients (27.1%) had positive cultures (60 cultures in total). Twenty-six patients had positive Cutibacterium acnes (C. acnes) cultures. On average, C. acnes cultures took 10.65 days to turn positive, whereas 24 of 27 patients had cultures that were positive within 14 days of the culture being obtained. There was no difference in infection incidence rates between soft tissue and bony stabilization procedures (P = .86) or arthroscopic and open procedures (P = .59). Males were more than 5 times more likely than females to be culture positive in our cohort (93.1% vs. 73.1%, relative risk [RR] = 1.27, P = .03). Finally, 10 control cultures were taken from the operating room air environment (8 distinct surgeries had 1 control culture taken, whereas 1 surgery had 2), 2 of which were positive for C. acnes (both taken from the same patient operation). This patient had their shoulder cultures positive for C. acnes as well.

CONCLUSION

More than a quarter of patients requiring revision surgery after shoulder stabilization procedures have a subclinical shoulder infection, with males being at a higher risk of developing an infection than females. Surgeons should always consider infection as a reason for the lack of clinical improvement and possibly needing revision surgery after shoulder stabilization. The prompt diagnosis and treatment of these infections could be vital in improving results after these surgeries.

A High Rate of Bacteriologic Culture-Positive Findings Is Seen After Revision Rotator Cuff Surgery

Purpose

To determine the incidence of subclinical infections in patients undergoing revision arthroscopic rotator cuff repair and identify any risk factors for developing these infections.

Methods

Patients who underwent revision surgery by the senior author between January 2012 and December 2022 after a previous rotator cuff surgery were identified. All patients undergoing an open or arthroscopic revision of their previous rotator cuff surgery were included. Patients who had noted previous shoulder infections or had incomplete chart documentation were excluded. For each patient, demographic information, surgical information, and culture results were recorded.

Results

A total of 115 patients were identified. Thirty-nine were excluded due to incomplete chart documentation (35) or a history of infection (4); therefore, 22 patients (28.9%) had positive cultures (31 cultures in total). Seventeen patients had only Cutibacterium acnes identified. C acnes cultures turned positive on average 13.52 days after culture collection. There was no difference in infection incidence rates between isolated rotator cuff repair and rotator cuff repair plus additional surgeries (P = .88) or between initial arthroscopic versus open procedures (P = .83). None of the 12 identified risk factors, including age, sex, race, smoking history, previous corticosteroid injections, malnutrition, renal failure, liver failure, diabetes mellitus, immunocompromised status, intravenous drug use, and number of revisions, were correlated with the presence of a subclinical infection. Finally, 6 patients had control cultures taken. One culture (16.6%) was positive for C acnes, while this patient did not have a positive shoulder culture.

Conclusions

Subclinical shoulder infections can be present in more than one-quarter of patients undergoing revision after rotator cuff repair.

Level of Evidence

Level IV, diagnostic case series.

Extended skin cleaning on the shoulder with chlorhexidine reduces the cutaneous bacterial load but fails to decrease suture contamination in patients undergoing arthroscopy rotator cuff repair

BACKGROUND

It remains unclear whether preoperative skin cleaning of the chin, neck, and chest with chlorhexidine soap can reduce suture contamination by Cutibacterium acnes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included patients who underwent primary arthroscopic rotator cuff repair. Exclusion criteria included age <18 years, previous shoulder surgery, history of shoulder infection, and allergy to chlorhexidine. Patients were randomized into 3 groups. Patients in the control group cleaned their skin with soap and water, as usual. Patients in the shoulder group cleaned their shoulders with chlorhexidine soap 3 days before surgery, whereas patients in the extended shoulder group additionally cleaned their chest, back, neck, and face with chlorhexidine soap. On the day of surgery, skin swab samples were obtained from the shoulder after surgical draping. After rotator cuff repair, sutures were cut from the anchor ends. Both traditional culture methods and polymerase chain reaction (PCR) were used.

RESULTS

Ninety patients were enrolled (32 in the control group, 29 in the shoulder group, and 29 in the extended shoulder group) in the present study. The culture-positive rate from the posterior shoulder skin samples in the extended shoulder group (17.2%) was significantly lower than that in the control (40.6%) and shoulder (48.3%) groups (P = .036), whereas the culture-positive rates were not different among the 3 groups in other skin samples as well as the suture samples. The detection rates of C acnes in suture samples were 12.5%, 13.8%, and 17.2% in the control, shoulder, and extended shoulder groups, respectively (P = .603).

CONCLUSION

Extensive skin cleaning of the shoulder region with chlorhexidine helps reduce the shoulder cutaneous bacterial load, but the detection of C acnes suture contamination in patients undergoing arthroscopic rotator cuff repair remained untouched regardless of the use of chlorhexidine soap in skin cleaning on the preoperative days.

Preoperative topical benzoyl peroxide treatment is effective in reducing Cutibacterium acnes in shoulder surgery: a systematic review

BACKGROUND

Cutibacterium acnes (C acnes) colonization can have a significant impact on patients undergoing both arthroscopic and open shoulder surgery with regard to postoperative infection. Its resistance to standard preoperative skin preparations and prophylactic antibiotics has led to a need for a more targeted therapy. Topical benzoyl peroxide (BPO) has been used by dermatologists in the treatment for acnes due to its bactericidal and penetrative effects through the dermal layer. The aim of this systematic review is to review the effectiveness of topical BPO preoperatively in shoulder surgery in reducing C acnes colonization and postoperative infection.

METHODS

A review of the online databases Medline and Embase was conducted on December 15, 2021, according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting superficial and deep sample microbiology and postoperative complications were included. The studies were appraised using the revised Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies and the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

The search strategy identified 10 studies for inclusion (6 randomized control trials, 2 prospective cohort studies, and 2 case series), including a total of 482 patients. Seven studies were comparable, testing BPO against alternative standard skin preparations. Of the 10 studies, 7 showed a decrease in the load of C acnes on the skin and/or deep tissues, of which 6 demonstrated statistical significance. Men were shown to have a statistically significant increase in the colonization rate of C acnes. Scheer et al (2021) demonstrated 4500 colony-forming units/mL in males and 900 colony-forming units/mL in females. In studies where the number of BPO applications was higher, BPO appeared more effective. Dizay et al demonstrated C acnes elimination in 78.9% with more than 1 application compared with 66.7% if only applied once. Three studies looked at the effectiveness of BPO during the operative timeline with 1 demonstrating its statistically significant effectiveness at reducing colonization 2 hours into the operation (P = .048).

CONCLUSION

BPO is effective as a topical treatment at reducing C acnes colonization before shoulder surgery. However, the relationship between duration of treatment, frequency of application, and gender requires further research.

Topical Treatments in Reducing Propionibacterium Acnes Infection in Shoulder Surgery: Protocol for a Systematic Review and Meta-analysis

Introduction:

Propionibacterium acnes is a gram-positive anaerobe that is found on the dermis and epidermis of the shoulder and is the most commonly identifiable cause of periprosthetic shoulder joint infection. Various topical strategies have been investigated to reduce the prevalence of P acnes, with several demonstrating efficacy in reducing the positive culture. The aim of this systematic review and meta-analysis is to review the literature to assess the effectiveness of topical preparations in reducing the prevalence of P acnes in shoulder surgery.

Methods:

The study protocol was designed and registered prospectively on PROSPERO (International prospective register for systematic reviews). Databases used for the literature search will include MEDLINE, EMBASE, PsycINFO, and The Cochrane Library. Randomised controlled trials (RCTs) evaluating the use of any topical preparation against placebo, in all types of shoulder surgery, will be included. Our primary outcome is the number of colony forming units of P acnes. Secondary outcomes will include adverse events such as skin irritation, wound dehiscence, and the incidence of revision surgery due to infection. The Cochrane Risk of Bias Tool 2.0 and Jadad score will be used to assess the quality of methodology of the studies. Statistical analysis will be used to assess inconsistency and bias across included studies. Comparable outcome data will be pooled and analysed quantitatively or qualitatively as appropriate.

Ethics and dissemination:

No ethical clearances required for this study. This systematic review and meta-analysis will be published in a peer-reviewed journal.

Highlights

Registration:

PROSPERO 2022 CRD42022310312.

The efficacy of topical preparations in reducing the incidence of Cutibacterium acnes at the start and conclusion of total shoulder arthroplasty: a randomized controlled trial

BACKGROUND

Preoperative skin preparations for total shoulder arthroplasty (TSA) are not standardized for Cutibacterium acnes eradication. Topical benzyl peroxide (BPO) and benzyl peroxide with clindamycin (BPO-C) have been shown to reduce the bacterial load of C acnes on the skin. Our aim was to investigate whether preoperative application of these topical antimicrobials reduced superficial colonization and deep tissue inoculation of C acnes in patients undergoing TSA.

METHODS

In a prospective, single-blinded randomized controlled trial, 101 patients undergoing primary TSA were randomized to receive either topical pHisoHex (hexachlorophene [1% triclosan; sodium benzoate, 5 mg/mL; and benzyl alcohol, 5 mg/mL]) (n = 35), 5% BPO (n = 33), or 5% BPO with 1% clindamycin (n = 33). Skin swabs obtained prior to topical application and after topical application before surgery, as well as 3 intraoperative swabs (dermis after incision, on joint capsule entry, and dermis at wound closure), were cultured. The primary outcome was positive culture findings and successful decolonization.

RESULTS

All 3 topical preparations were effective in decreasing the rate of C acnes. The application of pHisoHex reduced skin colonization by 50%, BPO reduced skin colonization by 73.7%, and BPO-C reduced skin colonization by 81.5%. The topical preparation of BPO-C was more effective in decreasing the rate of C acnes at the preoperative and intraoperative swab time points compared with pHisoHex and BPO (P = .003). Failure to eradicate C acnes with topical preparations consistently resulted in deep tissue inoculation. There was an increase in the C acnes contamination rate on the skin during closure (33%) compared with skin cultures taken at surgery commencement (22%).

CONCLUSION

Topical application of BPO and BPO-C preoperatively is more effective than pHisoHex in reducing colonization and contamination of the surgical field with C acnes in patients undergoing TSA.

Efficacy of Three Povidone Iodine Formulations against Cutibacterium acnes Assessed through In Vitro Studies: A Preliminary Study

Cutibacterium acnes (C. acnes, formerly known as Propionibacterium acnes) is the major causative agent of prosthetic joint infections (PJI). Treatment of PJI with antibiotics is difficult due to antibiotic resistance and adverse side effects on patients’ health. Proper disinfection of the surgical site using a variety of povidone iodine formulations could prevent C. acnes infection. In the current study, the efficacy of the three povidone iodine (PVP-I) formulations, viz: PVP-I 10% dermic solution, PVP-I 5% alcoholic solution and PVP-I 4% scrub, was tested against C. acnes, in vitro, in the presence of interfering substances mimicking soiling conditions. C. acnes strain ATCC 6919 was used to test the bactericidal activity of the povidone iodine formulations according to the modified dilution-neutralization method described in French Norm EN standard 13727. A 3-log reduction in the bacterial cell count in 60 s was considered to be significant. The results showed that under experimental conditions, the three PVP-I formulations displayed bactericidal activity against the micro-organism, Cutibacterium acnes, and that the lowest concentration of povidone-iodine active against C. acnes was 0.4%. These results are encouraging as PVP-I offers a low-cost and efficient method of disinfection.

Occult clavicle osteomyelitis caused by Cutibacterium acnes (C. acnes) after coracoclavicular ligament reconstruction: A case report and review of the literature

INTRODUCTION

Clavicle osteomyelitis is a rare, but serious complication following operative repair of acromioclavicular (AC) joint separations. Cutibacterium Acnes (C. acnes) is rarely a causative pathogen in clavicle osteomyelitis and diagnosis can be challenging due to the indolent nature of this organism.

CASE PRESENTATION

A 45-50 year old female with a chronic AC joint separation underwent an open coracoclavicular reconstruction using semitendinosus allograft and FiberTape (Arthrex, Naples, FL). At the six month follow up, the patient complained of mild persistent pain. Imaging demonstrated widening of the medial suture tunnel with distal clavicle osteolysis, which was concerning for osteomyelitis. This was successfully treated with implant removal revision surgery and additional intravenous antibiotics. Cultures of the graft material were positive for C. acnes. The patient continued to have osteolysis of the distal left clavicle for a period of time despite resolution of osteomyelitis.

DISCUSSION

C. acnes osteomyelitis of the clavicle is difficult to diagnose because of its vague associated symptoms when implicated in infections. There are no known obvious predisposing factors for C. acnes clavicle osteomyelitis. Literature suggests management should include aggressive irrigation and debridement, removal of any hardware, and extended intravenous antibiotic administration.

CONCLUSION

C. acnes clavicular osteomyelitis is uncommon, thus established treatment guidelines have not yet been formed. Revision surgery to remove graft material, irrigate, and debride in addition to antibiotic treatment was successful for our patient. Additional pathologic manifestations of C. acnes infections could include continued clavicular erosion post-clearance of infection, although further investigation is necessary.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

The management of the shoulder skin microbiome (Cutibacterium acnes) in the context of shoulder surgery: a review of the current literature

BACKGROUND

This review aims to establish current knowledge of the shoulder skin microbiome and how to manage the bacteria that reside within it.

METHODS

A review was undertaken of the current literature through OvidSP. All abstracts were reviewed by three independent researchers.

RESULTS

Thirty-five studies met the inclusion criteria. With forward referencing an additional 14 were included. None commented on organisms specific to the shoulder microbiome other than Cutibacterium acnes. Therefore, this review is focussed on the current knowledge of C. acnes.

DISCUSSION

C. acnes is a skin commensal within the pilo-sebaceous glands reported to be the primary pathogen in up to 86% of shoulder joint infections. Pre-operative culture of unprepared skin can be indicative of underlying joint infection in shoulder arthroplasty revision. Intra-articular biopsies may have a high false positive due to skin contamination. Correlating the number of positive samples and certain associated signs can give a greater than 90% probability of a true infection. Standard surgical skin preparation, peri-surgical intravenous antibiotics and oral pre-operative antibiotics do not reduce bacterial load within the skin. However, topical benzoyl peroxide and clindamycin have both demonstrated significantly reduced bacteria load. Phylogenetically there are six main types. Patients may have more than one phenotype present during infection.

Hydrogen Peroxide Does Not Significantly Reduce Cutibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair

PURPOSE

To evaluate the efficacy of application of the 3% hydrogen peroxide (HP)-soaked gauze as an addition to the standard preoperative sterile skin preparation for Cutibacterium acnes suture contamination in arthroscopic rotator cuff repairs.

METHODS

A prospective randomized study was undertaken to evaluate 151 consecutive patients undergoing arthroscopic rotator cuff repair. Each shoulder was prepared with 1 of the 2 randomly selected protocols: chlorhexidine alcohol (1% chlorhexidine gluconate in 70% isopropyl alcohol)(control group) and chlorhexidine alcohol with 3% HP (HP-treated group). In the HP-treated group, the 3% HP-soaked gauze was applied over the shoulder for 5 minutes before the application of the chlorhexidine-alcohol. The first cut-tails of the anchor suture after cuff fixation were submitted to aerobic and anaerobic cultures. Patients were clinically evaluated for infection 10 days, 28 days, 3 months, 6 months, and 12 months after surgery.

RESULTS

The rate of C acnes-positive cultures was 13.0% (10 of 77 cases) in the control group and 6.8% (5 of 74 cases) in the HP-treated group. The HP-treated group showed a trend of lower C acnes-positive culture rate, which did not reach statistical significance (relative risk, 0.52; 95% confidence interval, 0.19 and 1.45; number needed to treat, 16.1; P = .20). One case of coagulase-negative Staphylococcus (Staphylococcus intermedius) was isolated in the HP-treated group (1 of 74 cases, 1.3%). No other bacteria were isolated. No infections occurred in any of the patients treated in this study during the minimum 3-month follow-up period. One patient in the HP-treated group complained of skin irritation.

CONCLUSIONS

The use of a 3% HP-soaked gauze as an addition to the standard preoperative sterile skin preparation for arthroscopic rotator cuff repairs showed only a marginal effect (statistically insignificant) in reducing the C acnes suture contamination rate in the arthroscopic rotator cuff repair patients.

LEVEL OF EVIDENCE

I, prospective, randomized trial.