These authors point out that Cutibacterium is the main pathogen in periprosthetic shoulder infections (PSI) and that in acne vulgaris therapy, Benzoyl Peroxide and Miconazole Nitrate cream reduces the superficial Cutibacterium burden of the skin.
The goal of their study was to investigate the efficacy of a topical acne vulgaris cream (Benzoyl Peroxide; Miconazole Nitrate - 50 mg/g BPO and 20 mg/g MN,) in reducing subcutaneous and capsular Cutibacterium in individuals with Cutibacterium skin colonization in open shoulder surgery.
They conducted a prospective randomized pilot trial, allocating 60 adult patients (1:1) between a 7-days-preoperative application of a commercial acne cream (Benzoyl Peroxide; Miconazole Nitrate) on the preoperative skin (intervention group) versus no cream (controls). The cost of one-week therapy with the cream was about $11.
One week before surgery, and before the first application of the cream, the superficial skin over the planned shoulder incision was swabbed (sample 1) for microbiological cultures. The same skin swabbing (sample 2) was repeated in the operating room immediately before disinfection with povidone-iode, isoprophyl-alcohol and ethanol. The perioperative antibiotic prophylaxis comprised cefuroxime 1.5g intravenously tid for 24 hours. During surgery, two deep intraoperative biopsies were obtained from the subcutaneous (sample 3) and capsular tissue (sample 4).
Sixty patients (mean age 59 years, 55% females) with primary open shoulder surgery were included.
At baseline, Cutibacterium was present on the skin in 60% (18/30 in the intervention group; 19/30 in the controls.
In these patients with Cutibacterium skin colonization, application of acne cream resulted in an apparent reduction of the number of positive intraoperative capsular samples (0/18 vs. 4/19). However two of our statistical colleagues pointed out that this study used the Chi Square test to consider the significance of this difference of p 0.04. The Chi Square test is not appropriate with a count of 0. A Fisher's exact test is more appropriate and yields a p value of 0.105, i.e. not significant. The intervention resulted in a significant reduction of the overall number of positive intraoperative samples compared to the control group (8/18 vs. 16/19; Fishers exact p=0.02).
One patient showed an adverse reaction to the cream and was excluded from the per-protocol analysis.
It is recognized that systemic antibiotics cannot eliminate Cutibacterium from shoulder surgical wounds and carry the risk of creating resistant germs. Standard preoperative skin preparation is also ineffective in eliminating Cutibacterium from shoulder surgical wounds.
Benzoyl Peroxide (BPO) is known to have a bactericidal effect on Cutibacterium, but carries the risk of skin irritation. Miconazole Nitrate (MN) is an imidazole derivative that interferes with lipid synthesis and membrane permeability. The author suggest that the synergistic MN favors the penetration of BPO into the bacterial cells and ultimately supports a better tolerability of the topical combination therapy. See Efficacy and tolerance of a miconazole-benzoyl peroxide cream combination versus a benzoyl peroxide gel in the topical treatment of acne vulgaris, which concluded that this combination supports a better tolerability of BPO.
Further study will be needed to clarify the value of this combination of agents in reducing the load of Cutibacterium in the deep tissues of the shoulder,
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