Sunday, December 28, 2014

Propionibacterium - they can't always be kept out of the shoulder arthroplasty field!

Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis

Recognizing that propionibacterium are commonly recovered from deep cultures obtained at the time of revision arthroplasty, these authors sought to determine whether deep cultures obtained at the time of primary arthroplasty could be substantially positive for Propionibacterium despite thorough skin preparation and aggressive preoperative intravenous antibiotic prophylaxis.

After timely administration of preoperative antibiotics - Ceftriaxone and Vancomyin - chosen specifically for their activity against Propionibacterium and after double skin preparation, specimens from the dermis, fascia, capsule, synovium, and glenoid tissue were sterilely harvested from 10 male patients undergoing primary shoulder arthroplasty and were submitted for culture for Propionibacterium.

Of the 50 specimens, 7 were positive for Propionibacterium: 3 in each of 2 patients and 1 in 1 patient. The specimen sources having positive anaerobic cultures were the dermis (1 of 10), fascia (2 of 10), synovium (1 of 10), and glenoid tissue (3 of 10). None of these patients had evidence of infection at the time of the arthroplasty.

The authors concluded that preoperative antibiotics and skin preparation do not always eliminate Propionibacterium from the surgical field of primary shoulder arthroplasty. The presence of these bacteria in the arthroplasty wound may pose a risk of delayed shoulder arthroplasty failure from the subtle type of periprosthetic infection typically associated with Propionibacterium.

Comment: These observations indicate that aggressive prophylaxis with systemic antibiotics and vigorous skin preparation are not always successful in eliminating Propionibacterium from the wounds of male patients undergoing shoulder arthroplasty.

This finding may encourage surgeons to assume that the surgical field may harbor these organisms - either because they were there preoperatively or because they were seeded from the hair follicles and sebaceous glands of the dermis at the time of skin incision. This realization may prompt the use of copious irrigation with antibiotic-containing saline solution and careful handling of the prostheses in an effort to minimize the number of Propionibacterium contacting the prosthesis and to reduce the risk of biofilm formation on the implants.

Patients having shoulder arthroplasty - especially males -  should be informed of the risk of delayed presentation of Propionibacterium, which may include pain, stiffness or component loosening without the usual clinical signs of infection.

We have come to recognize the "honeymoon" phenomenon - a period of initially excellent comfort and function after a shoulder arthroplasty followed by the progressive onset of stiffness and pain. When they honeymoon is over, concern for the effects of Propionibacterium rises.


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