Thursday, April 7, 2016

Propionibacterium in Shoulder Arthroplasty: What We Think We Know Today

Propionibacterium in Shoulder Arthroplasty What We Think We Know Today

These authors try to bring us up to date about the elusive problem of Propionibacterium in shoulder arthroplasty.


*Propionibacterium is a slow-growing gram-positive rod that is part of the normal skin microbiome.

*Propionibacterium is often isolated from deep specimens obtained at revision surgery for failed shoulder arthroplasty after a 'stealth' presentation  (pain, stiffness, or component loosening), rather with the 'obvious' presentation often seen with failed hip and knee replacements (swelling, erythema, drainage, or tenderness).

*Propionibacterium-positive shoulder arthroplasty failure may present months or years after a ''honeymoon" period of good recovery with unexplained pain, stiffness, or component loosening.

*Not all Propionibacterium are the same: certain subtypes may be enriched with virulence factors. In addition to P. Acnes, P. Avidum, P. Granulosum, and P Humerusii have been recovered from failed shoulder arthroplaties. Propionibacterium may co-exist with coagulase negative Staph in a failed arthroplasty - it is possible that such a combined infection may be more difficult to treat.

*Because Propionibacterium typically reside in the dermal pilosebaceous glands of the oily skin of the chest, standard epidermal surgical preparation cannot prevent live bacteria from being liberated into the surgical wound when the skin incision cuts through these glands.

*Perioperative antibiotics may fail to produce bactericidal levels in the relatively avascular pilosebaceous glands, further increasing the risk of introduction of Propionibacterium into the surgical wound.

Steps to avoid Propionibacterium colonization of a prosthesis may include (1) inserting the implant with fresh gloves, (2) copious irrigation of the wound with antibiotic-saline solution, (3) preventing contact between the prosthesis and the cut skin edge, and (4) use of topical antibiotics around the implant.

* Propionibacterium tend to form biofilms in soft tissues and on the surface of arthroplasty implants, where they are protected from systemic and topical antibiotics. This has two adverse effects: (1) fluid aspirates (which attempt to isolate planktonic bacteria) may be culture negative in the presence of a culture positive biofilm and (2) elimination of a Propionibacterium-ladened biofilm may require removal of the affected prosthetic components.

*Isolation of Propionibacterium from a surgical wound is optimized if five tissue or explant specimens are cultured on aerobic and anaerobic media and observed for 17 days.

*Treatment of a Propionibacterium-positive failed arthroplasty can be difficult, often requiring prosthesis exchange and vigorous, prolonged antibiotic therapy.

*It is suggested that Ceftriaxone may be more effective against Propionibacterium  than Cephalexin or Clindamycin.

*As pointed out in a recent article (see this link), Propionibacterium  is not just a shoulder problem.


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