Advertisement
Journal of Shoulder and Elbow Surgery

Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery

      Background

      Propionibacterium acnes infection is a significant problem after shoulder surgery. Residual P. acnes is found on the skin up to 29% of the time immediately after surgical skin preparation and in 70% of dermal biopsy specimens. These residual bacteria may be a source for infection. Identifying more ideal skin preparation may help reduce the risk of infection. The purpose of this study was to evaluate the effect that topical benzoyl peroxide (BPO), with chlorhexidine skin preparation, would have on the presence of P. acnes cultured at the time of shoulder surgery. We hypothesized that adding topical BPO to our skin preparation would reduce the number of positive P. acnes cultures identified during surgery.

      Methods

      Fifty patients undergoing first-time shoulder surgery were treated with topical 5% BPO cream 48 hours before surgery. After skin preparation, 13 samples per subject were obtained. Cultures were held for 14 days.

      Results

      Fifty patients underwent arthroscopic shoulder surgery; 650 culture specimens were obtained. The skin was positive at the initiation of surgery in 6% of cases. Tissue samples were positive in 6%. The skin was positive in 10% at the end of surgery. None of these rates of positive culture were different from the 4% rate observed with a control swab.

      Conclusion

      Application of BPO is an effective way to reduce P. acnes on skin at the beginning and, importantly, at the end of a surgical procedure. This may result in a lower risk for postoperative infection.

      Level of evidence

      Keywords

      To read this article in full you will need to make a payment

      References

        • Amin K.
        • Riddle C.C.
        • Aires D.J.
        • Schweiger E.S.
        Common and alternate oral antibiotic therapies for acne vulgaris: a review.
        J Drugs Dermatol. 2007; 6: 873-880
        • Bayston R.
        • Ashraf W.
        • Barker-Davies R.
        • Tucker E.
        • Clement R.
        • Clayton J.
        • et al.
        Biofilm formation by Propionibacterium acnes on biomaterials in vitro and in vivo: impact on diagnosis and treatment.
        J Biomed Mater Res A. 2007; 81: 705-709https://doi.org/10.1002/jbm.a.31145
        • Butler-Wu S.M.
        • Burns E.M.
        • Pottinger P.S.
        • Magaret A.S.
        • Rakeman J.L.
        • Matsen 3rd, F.A.
        • et al.
        Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection.
        J Clin Microbiol. 2011; 49: 2490-2495https://doi.org/10.1128/JCM.00450-11
        • Cheung E.V.
        • Sperling J.W.
        • Cofield R.H.
        Revision shoulder arthroplasty for glenoid component loosening.
        J Shoulder Elbow Surg. 2008; 17: 371-375https://doi.org/10.1016/j.jse.2007.09.003
        • Dramis A.
        • Aldlyami E.
        • Grimer R.J.
        • Dunlop D.J.
        • O’Connell N.
        • Elliott T.
        What is the significance of a positive Propionibacterium acnes culture around a joint replacement?.
        Int Orthop. 2009; 33: 829-833https://doi.org/10.1007/s00264-008-0534-y
        • Fulton J.E.
        • Farzad-Batshandeth A.
        Studies on the mechanism of action of topical benzyl peroxide in acne vulgaris.
        J Cutan Pathol. 1974; 1: 194-200
        • Gollnick H.
        • Cunliffe W.
        • Berson D.
        • Dreno B.
        • Finlay A.
        • Leyden J.L.
        • et al.
        Management of acne: a report from a global alliance to improve outcomes in acne.
        J Am Acad Dermatol. 2003; 49: S1-S37https://doi.org/10.1067/mjd.2003.618
        • Haider A.
        • Shaw J.C.
        Treatment of acne vulgaris.
        JAMA. 2004; 292: 726-735https://doi.org/10.1001/jama.292.6.726
        • Hasan S.S.
        • Leith J.M.
        • Campbell B.
        • Kapil R.
        • Smith K.L.
        • Matsen 3rd, F.A.
        Characteristics of unsatisfactory shoulder arthroplasties.
        J Shoulder Elbow Surg. 2002; 11: 431-441https://doi.org/10.1067/mse.2002.125806
        • Hudek R.
        • Sommer F.
        • Kerwat M.
        • Abdelkawi A.F.
        • Loos F.
        • Gohlke F.
        Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?.
        J Shoulder Elbow Surg. 2014; 23: 1763-1771https://doi.org/10.1016/j.jse.2014.05.024
        • Kelly 2nd, J.D.
        • Hobgood E.R.
        Positive culture rate in revision shoulder arthroplasty.
        Clin Orthop Relat Res. 2009; 467: 2343-2348https://doi.org/10.1007/s11999-009-0875-x
        • Lee M.J.
        • Pottinger P.S.
        • Butler-Wu S.
        • Bumgarner R.E.
        • Russ S.M.
        • Matsen 3rd, F.A.
        Propionibacterium persists in the skin despite standard surgical preparation.
        J Bone Joint Surg Am. 2014; 96: 1447-1450https://doi.org/10.2106/JBJS.M.01474
        • Levy O.
        • Iyer S.
        • Atoun E.
        • Peter N.
        • Hous N.
        • Cash D.
        • et al.
        Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?.
        J Shoulder Elbow Surg. 2013; 22: 505-511https://doi.org/10.1016/j.jse.2012.07.007
        • Leyden J.J.
        Effect of topical benzoyl peroxide/clindamycin versus topical clindamycin and vehicle in the reduction of Propionibacterium acnes.
        Cutis. 2002; 69: 475-480
        • Leyden J.J.
        • Del Rosso J.Q.
        • Webster G.F.
        Clinical considerations in the treatment of acne vulgaris and other inflammatory skin disorders: focus on antibiotic resistance.
        Cutis. 2007; 79: 9-25
        • Matsen 3rd, F.A.
        • Butler-Wu S.
        • Carofino B.C.
        • Jette J.L.
        • Bertelsen A.
        • Bumgarner R.
        Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites.
        J Bone Joint Surg Am. 2013; 95: e1811-e1817https://doi.org/10.2106/JBJS.L.01733
        • McLorinan G.C.
        • Glenn J.V.
        • McMullan M.G.
        • Patrick S.
        Propionibacterium acnes wound contamination at the time of spinal surgery.
        Clin Orthop Relat Res. 2005; : 67-73
        • Patel A.
        • Calfee R.P.
        • Plante M.
        • Fischer S.A.
        • Green A.
        Propionibacterium acnes colonization of the human shoulder.
        J Shoulder Elbow Surg. 2009; 18: 897-902https://doi.org/10.1016/j.jse.2009.01.023
        • Pottinger P.
        • Butler-Wu S.
        • Neradilek M.B.
        • Merritt A.
        • Bertelsen A.
        • Jette J.L.
        • et al.
        Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening.
        J Bone Joint Surg Am. 2012; 94: 2075-2083https://doi.org/10.2106/JBJS.K.00861
        • Saltzman M.D.
        • Marecek G.S.
        • Edwards S.L.
        • Kalainov D.M.
        Infection after shoulder surgery.
        J Am Acad Orthop Surg. 2011; 19: 208-218
        • Saltzman M.D.
        • Nuber G.W.
        • Gryzlo S.M.
        • Marecek G.S.
        • Koh J.L.
        Efficacy of surgical preparation solutions in shoulder surgery.
        J Bone Joint Surg Am. 2009; 91: 1949-1953https://doi.org/10.2106/JBJS.H.00768
        • Sethi P.M.
        • Sabetta J.R.
        • Stuek S.J.
        • Horine S.V.
        • Vadasdi K.B.
        • Greene R.T.
        • et al.
        Presence of Propionibacterium acnes in primary shoulder arthroscopy: results of aspiration and tissue cultures.
        J Shoulder Elbow Surg. 2015; 24: 796-803https://doi.org/10.1016/j.jse.2014.09.042