Topical Preparations for Reducing Cutibacterium acnes Infections in Shoulder Surgery: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Abstract

Background:

Cutibacterium acnes (C acnes) is a commensal skin bacterium, primarily found in sebaceous glands and hair follicles, with a high prevalence in the shoulder region. It is the most common pathogenic organism in prosthetic joint infections after shoulder arthroplasty. Because of its low virulence, its diagnosis remains difficult.

Purpose:

To evaluate the relative effects of topical preparations in reducing C acnes in shoulder surgery.

Study Design:

Meta-analysis; Level of evidence, 1.

Methods:

We searched the MEDLINE, Embase, PsychINFO, and Cochrane Library databases in March 2022. Randomized controlled trials (RCTs) comparing any form of topical preparation in arthroscopic or open shoulder surgery were included. The primary outcome was a reduction in the number of positive C acnes cultures. Secondary outcomes were adverse events related to the application of topical preparations. We performed a network meta-analysis to facilitate simultaneous comparisons between multiple preparations across studies. We calculated differences between preparations using odds ratios and their 95% CIs. The risk of bias was assessed using the Cochrane risk-of-bias tool.

Results:

The search yielded 17 RCTs (1350 patients), of which 9 were suitable for the network meta-analysis (775 patients). Overall, 2 RCTs were deemed as having a low risk of bias, and 15 raised “some concerns” of bias. Preparations included benzoyl peroxide (BPO), BPO combined with clindamycin, chlorhexidine gluconate, hydrogen peroxide, povidone-iodine, and water with soap. Only BPO resulted in significantly lower odds of a positive C acnes culture compared with placebo or soap and water (odds ratio, 0.12 [95% CI, 0.04-0.36]). There was no statistically significant difference with all other topical preparations. The only adverse events were skin irritation from BPO and chlorhexidine gluconate in a small number of reported cases.

Conclusion:

BPO was the most effective topical agent in reducing the prevalence of C acnes in shoulder surgery. These results were limited by a combination of indirect and direct data. Future studies should focus on establishing the optimal frequency and duration of preoperative BPO to further reduce the burden of C acnes.

Registration:

CRD42022310312 (PROSPERO).

Keywords

benzoyl peroxide chlorhexidine gluconate shoulder surgery shoulder arthroscopic surgery shoulder arthroplasty

Get full access to this article

View all access options for this article.

References

Achermann

Goldstein

Coenye

Shirtliff

ME.

Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen. Clin Microbiol Rev. 2014;27(3):419-440.

Aubin

Portillo

Trampuz

Corvec

Propionibacterium acnes, an emerging pathogen: from acne to implant-infections, from phylotype to resistance. Med Mal Infect. 2014;44(6):241-250.

Balshem

Helfand

Schunemann

, et al. GRADE guidelines, 3: rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-406.

Bucher

Guyatt

Griffith

Walter

SD.

The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials. J Clin Epidemiol. 1997;50(6):683-691.

Collins

Simpson

Richey

, et al. Efficacy of antimicrobial washes before shoulder surgery against Cutibacterium: a systematic review and meta-analysis. JSES Rev Rep Tech. 2022;2(3):315-322.

Cotter

Franczek

, et al. Efficacy of combinational therapy using blue light and benzoyl peroxide in reducing Cutibacterium acnes bioburden at the deltopectoral interval: a randomized controlled trial. J Shoulder Elbow Surg. 2021;30(12):2671-2681.

Dizay

Lau

Nottage

WM.

Benzoyl peroxide and clindamycin topical skin preparation decreases Propionibacterium acnes colonization in shoulder arthroscopy. J Shoulder Elbow Surg. 2017;26(7):1190-1195.

Doi

SAR

Barendregt

. A generalized pairwise modelling framework for network meta-analysis. Int J Evid Based Healthc. 2018;16(4):187-194.

Dörfel

Maiwald

Daeschlein

, et al. Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region. Antimicrob Resist Infect Control. 2021;10(1):17.

10.

Grewal

Polisetty

Boltuch

, et al. Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2021;30(8):1827-1833.

11.

Hancock

Rupasinghe

Elkinson

Bloomfield

Larsen

PD.

Benzoyl peroxide + chlorhexidine versus chlorhexidine alone skin preparation to reduce Propionibacterium acnes: a randomized controlled trial. ANZ J Surg. 2018;88(11):1182-1186.

12.

Higgins

Altman

Gotzsche

, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011;343:D5928.

13.

Hong

Hsu

Kuan

, et al. 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. J Shoulder Elbow Surg. 2023;32(4):744-750.

14.

Hsu

Neradilek

Russ

Matsen

3rd . Preoperative skin cultures are predictive of Propionibacterium load in deep cultures obtained at revision shoulder arthroplasty. J Shoulder Elbow Surg. 2018;27(5):765-770.

15.

Hsu

Whitson

Woodhead

, et al. Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients. Int Orthop. 2020;44(7):1325-1329.

16.

Kadler

Mehta

Funk

Propionibacterium acnes infection after shoulder surgery. Int J Shoulder Surg. 2015;9(4):139-144.

17.

Kolakowski

Lai

Duvall

, et al. Neer Award 2018. Benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2018;27(9):1539-1544.

18.

Levy

Iyer

Atoun

, et al. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013;22(4):505-511.

19.

Levy

Fenollar

Stein

, et al. Propionibacterium acnes postoperative shoulder arthritis: an emerging clinical entity. Clin Infect Dis. 2008;46(12):1884-1886.

20.

Matsen

3rd Butler-Wu

Carofino

, et al. Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites. J Bone Joint Surg Am. 2013;95(23):e1811-e1817.

21.

Matsen

3rd Russ

Bertelsen

Butler-Wu

Pottinger

PS.

Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis. J Shoulder Elbow Surg. 2015;24(6):844-847.

22.

Meyer

Lazarides

Hendren

, et al. The efficacy of peroxide solutions in decreasing Cutibacterium acnes burden around the shoulder. J Am Acad Orthop Surg. 2022;30(1):e91-e98.

23.

Moor

Leger

Steffen

, et al. Subcutaneous tissue disinfection significantly reduces Cutibacterium acnes burden in primary open shoulder surgery. J Shoulder Elbow Surg. 2021;30(7):1537-1543.

24.

Murray

Saltzman

Gryzlo

, et al. Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery. J Shoulder Elbow Surg. 2011;20(6):928-933.

25.

Patel

Calfee

Plante

Fischer

Green

Propionibacterium acnes colonization of the human shoulder. J Shoulder Elbow Surg. 2009;18(6):897-902.

26.

Qiu

Pena-Diaz

, et al. Cutibacterium acnes and the shoulder microbiome. J Shoulder Elbow Surg. 2018;27(10):1734-1739.

27.

Rucker

Network meta-analysis, electrical networks and graph theory. Res Synth Methods. 2012;3(4):312-324.

28.

Saltzman

Nuber

Gryzlo

Marecek

Koh

JL.

Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009;91(8):1949-1953.

29.

Scheer

Bergman Jungestrom

Lerm

Serrander

Kalen

Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study. J Shoulder Elbow Surg. 2018;27(6):957-961.

30.

Scheer

Jungestrom

Serrander

Kalen

Scheer

JH.

Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure. J Shoulder Elbow Surg. 2021;30(6):1316-1323.

31.

Stull

Nicholson

Davis

Namdari

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2020;29(2):212-216.

32.

Symonds

Grant

Doma

, et al. 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. J Shoulder Elbow Surg. 2022;31(6):1115-1121.

33.

Unterfrauner

Wieser

Catanzaro

Uckay

Bouaicha

Acne cream reduces the deep Cutibacterium acnes tissue load before elective open shoulder surgery: a randomized controlled pilot trial. J Shoulder Elbow Surg. 2022;31(5):897-905.

34.

van Diek

Pruijn

Spijkers

, et al. The presence of Cutibacterium acnes on the skin of the shoulder after the use of benzoyl peroxide: a placebo-controlled, double-blinded, randomized trial. J Shoulder Elbow Surg. 2020;29(4):768-774.

35.

Yamakado

Hydrogen peroxide does not significantly reduce Cutibacterium acnes suture contamination in arthroscopic rotator cuff repair. Arthroscopy. 2021;37(4):1134-1140.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.11 MB