Removing Cutibacterium from the Skin

It is generally recognized that Cutibacterium originating from the patient's skin is the commonest organism associated with shoulder periprosthetic infections. While these organisms normally populate the skin's epidermal surface, they reside in the pilosebaceous units of the dermis - especially in the areas over the shoulder, back and face and especially in male patients. The surgical incision for shoulder arthroplasty must transect many of these structures, allowing the Cutibacterium to fall into the wound, potentially contaminating the arthroplasty.

Surgeons routinely "prep the skin" with various solutions, however the effectiveness of a skin surface prep has been shown to be suboptimal given the subsurface location this bacterial reservoir. 

Some authors have indicated that the addition of hydrogen peroxide (H2O2) may increase the effectiveness of a chlorhexidine gluconate (CHG) prep (which is the most common solution applied before shoulder arthroplasty).

The authors of Does adding hydrogen peroxide to chlorhexidine gluconate increase the effectiveness of skin preparation in reducing cutaneous Cutibacterium levels? A randomized controlled trial studied eighteen male volunteers; the two shoulders of each volunteer were randomized to receive either (A) the control preparation - 2% CHG in 70% isopropyl alcohol alone (CHG) or (B) 3% H2O2 followed by 2% CHG in 70% isopropyl alcohol (H2O2!CHG). 

Skin swabs were taken from each shoulder prior to skin preparation and again at 60 minutes after preparation. Swabs were cultured for Cutibacterium and observed for 14 days. Cutibacterium skin load was reported using a semiquantitative system based on the number of quadrants growing on the culture plate, thus the range for the Specimen Cutibacterium Value (SpCuV) is 0 to 4. This is an example of a 4, all four quadrants have growth.

Prior to skin preparation, 100% of the CHG-only shoulders and 100% of the H2O2!CHG shoulders had positive skin surface cultures for Cutibacterium. 

The mean SpCuV for the CHG-only shoulders prior to preparation was 2.1 +/- 0.8.
The mean baseline SpCuV for the H2O2!CHG shoulders prior to preparation  was 2.2 +/- 0.7.

The mean SpCuV for the CHG-only shoulders 60 minutes after preparation was 1.3 +/- 0.9.
The mean SpCuV for the H2O2!CHG shoulders 60 minutes after preparation was 1.4 +/- 0.9 

There was a reduction of Cutibacterium load at 60 minutes in 10 (56%) of the CHG-only shoulders.
There was a reduction of Cutibacterium load at 60 minutes in 11 (61%) of the H2O2!CHG shoulders.

The mean reduction in SpCuV at 60 minutes was 0.8 for the CHG-only group
The mean reduction in SpCuV at 60 minutes was 0.8 for the H2O2!CHG group.

After 60 minutes, Cutibacterium had repopulated the skin surface on 14 (78%) of the CHG-only shoulders.
After 60 minutes, Cutibacterium had repopulated the skin surface on 14 (78%) of the H2O2!CHG shoulders.

Comment: These data corroborate other studies indicating that Cutibacterium cannot be removed from the skin by skin preparation of the shoulder. 

While skin surface preparations may be of some value in temporarily reducing the load of these organisms, a combination of host defenses along with intraoperative and postoperative prophylactic measures must be relied on to defend the shoulder against periprosthetic infection.

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How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
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The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Predicting infection risk in shoulder arthroplasty

Cutaneous microbiology of patients having primary shoulder arthroplasty

These authors point out that shoulder periprosthetic infections are predominantly caused by bacteria residing in the skin of healthy individuals.

They tested the hypothesis that easy-to-obtain preoperative characteristics were significantly associated with the cutaneous microbiology and the loads of specific bacteria in shoulders having joint replacement.

They identified the microbiology of the unprepared epidermal skin surface and of the dermal edge freshly incised at surgery in 332 patients having primary shoulder arthroplasty.

The load of bacteria in each sample was characterized as a value based on the laboratory report: 0 for “no growth”; 0.1 for “one colony only” or for “broth only”; and 1, 2, 3, and 4 for 1+, 2+, 3+, and 4+ growth, respectively.

Cultures of the unprepared epidermal skin surface showed positive results for a wide variety of organisms, including Cutibacterium in 72%, coagulase-negative Staphylococcus in 61%, and a spectrum of other organisms in 32%.

By contrast, cultures of the freshly incised dermal edge showed a great preponderance of Cutibacterium (34%) in comparison to low levels of coagulase-negative Staphylococcus (8%) and other organisms (2%).

An increased dermal load of Cutibacterium was significantly associated with male sex (p<.001), younger patient age (p<.001), American Society of Anesthesiologists class 1 (p 0.046), use of testosterone supplements (p 0.014), prior shoulder surgery (p 0.046, and higher Cutibacterium loads on the unprepared skin surface (p<.001)

They concluded that although the microbiology of the unprepared skin surface is diverse, the same is not true for the freshly incised dermis, where Cutibacterium is the predominant organism.

Readily available preoperative patient characteristics were significantly associated with the load of Cutibacterium in the incised dermis.

Preoperative cultures of the unprepared skin surface appear to be a new method for predicting the type and load of bacteria found in the freshly incised dermis at the time of surgery.

Comment:  Knowledge of the preoperative characteristics of patients likely to have high dermal loads of Cutibacterium may help identify those for whom extraordinary means of prophylaxis (such as Betadine lavage, in-wound topical antibiotics, extended postoperative antibiotics) may be indicated to reduce the risk of periprosthetic infection.

The relationship of male sex, young age, good health, and testosterone supplements to the dermal load of Cutibacterium is consistent with previous observations that higher levels of male sex hormones are associated with increased sebum production in dermal pilosebaceous units and a commensurate increase in the number of Cutibacterium in these dermal structures.

It is of interest that the risk factors for higher loads of Cutibacterium in the dermal incisions for elective shoulder arthroplasty are quite different from the risk factors characteristically associated with periprosthetic infections of the hip and knee, which include older age, female sex, diabetes, high ASA score, obesity, and Medicaid insurance coverage.

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Do Propionibacterium grow on hair?

Spatial and Environmental Variation of the Human Hair Microbiota
<ScientifiC Reports | (2018) 8:9017 | DOI:10.1038/s41598-018-27100-1>

These authors point out that the skin is a complex living ecosystem harboring diverse microbial communities. Its highly variable properties and influence of intrinsic and extrinsic factors creates unique microenvironments where niche-specific microbes thrive. As part of the skin, hair supports its own microbial habitat that is also intra and inter-personal variable.

They explored the hair microbiota from scalp and pubic regions in healthy adults to investigate how the hair shaft microenvironment varies microbially. Their results suggest that there are distinct differences between the microbial communities identified on hair shafts originating from different parts of the body. The taxonomic composition of the communities from different hair sources are most reminiscent of those identified from their associated cutaneous region.

Their study confirms that human hair shafts harbor unique bacterial communities, distinctive from that of the hair follicle and more reminiscent of its associated cutaneous region. Staphylococcus, a common genera found in the skin, was also found to be abundant in hair. However, Propionibacterium, a predominant bacterium that colonizes the skin and hair follicles, is noticeably absent in hair samples. The hair shaft environment may be unfavorable for growth of Propionibacterium which prefer low oxygen levels and high sebum content as that of the hair follicle.

Comment: This study suggests that hair removal may not be of major benefit in reducing the risk of Propionibacterium colonization of a surgical wound.

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Predicting the presence of Propionibacterium in the freshly incised dermis In primary shoulder arthroplasty.

Preoperative Skin-Surface Cultures Can Help to Predict the Presence of Propionibacterium in Shoulder Arthroplasty Wounds 

Propionibacterium species are commonly cultured from specimens harvested at the time of revision shoulder arthroplasty. These bacteria reside in normal sebaceous glands, out of reach of surgical skin preparation. The arthroplasty incision transects these structures, which allows Propionibacterium to inoculate the wound and to potentially lead to the formation of a biofilm on the inserted implant. To help identify patients who are at increased risk for wound inoculation, these authors investigated whether preoperative cultures of the specimens from the unprepared skin surface were predictive of the results of intraoperative cultures of dermal wound-edge specimens obtained immediately after incision of the surgically prepared skin.

Sixty-six patients (mean age, 66.1 ± 9.4 years [range, 37 to 82 years]; 73% male) undergoing primary shoulder arthroplasty had preoperative cultures of the unprepared skin surface and intraoperative cultures of the freshly incised dermis using special culture swabs.

For the first 50 patients, a control swab was opened to air during the same time that the dermal specimen was obtained.

The results for female and male patients were characterized as the Specimen Propionibacterium Value (SpPV). The authors then determined the degree to which the results of cultures of the skin surface specimens were predictive of the results of culture of the dermal specimens.

An example of this semiquantitative reporting is shown below for the 21-day cultures of specimens from a 42-year-old man who presented for a primary shoulder arthroplasty.
Fig. 1-A Results of the culture of a specimen from the unprepared skin surface. Combining the culture positivity for the 2 different species of Propionibacterium yielded an SpPV of 2.
Note that, despite the presence of these bacteria, the Gram smear was negative.
Fig. 1-B Results of the culture of a specimen from the freshly incised dermis. The SpPV was 3.
Fig. 1-C Results of the culture of the control swab. TheSpPVwas 0.

Results: The skin-surface SpPV was greater than 1 in 3 (17%) of the 18 female patients and in 34 (71%) of the 48 male patients (p <0.001).

The dermal SpPV was greater than 1 in 0 (0%) of the 18 female patients and in 19 (40%) of the 48 male patients (p < 0.001).

None of the control samples had an SpPV greater than 1.   The predictive characteristics of a skin-surface SpPV of greater than 1 for a dermal SpPV of greater than 1 were as follows: sensitivity, 1.00 (95% confidence interval [CI], 0.82 to 1.00); specificity, 0.62 (95% CI, 0.46 to 0.75); positive predictive value, 0.51 (95% CI, 0.34 to 0.68); and negative predictive value, 1.00 (95% CI, 0.88 to 1.00).

The authors concluded that preoperative culture of the unprepared skin surface can help to predict whether the freshly incised dermal edge is likely to be positive for Propionibacterium. This test may help to identify patients who may merit more aggressive topical and systemic antibiotic prophylaxis.

Comment: This study shows (1) the the freshly incised dermis is often culture positive for Propionibacterium in spite of surgical skin preparation for shoulder arthroplasty,  (2) that surgeons have the opportunity to use preoperative skin cultures to determine the likelihood that the shoulder arthroplasty wound will be culture-positive for Propionibacterium, and (3) the value of taking control cultures to assess the possibility of contamination in each operating room.


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What bugs are in the skin of normal folks? Do Propionibacterium keep the bad bugs out?

Propionibacterium acnes strain populations in the human skin microbiome associated with acne.


These authors compared the skin microbiome at the strain level and genome level of Propionibacterium acnes between 49 acne patients and 52 healthy individuals by sampling the pilosebaceous units on their noses.  Among the 101 subjects, 59 were female (31 acne patients and 28
normal subjects) and 42 were male (18 acne patients and 24 normal subjects). The average age of the acne cohort was 22.2, and the average age of the normal cohort was 29.6. The authors did not sort the results by sex.

Metagenomic analysis demonstrated that although the relative abundances of P. acnes were similar, 

the strain population structures were significantly different in the two cohorts (RT refers to the ribotype).

Certain strains were highly associated with acne, and other strains were enriched in healthy skin. By sequencing 66 previously unreported P. acnes strains and comparing 71 P. acnes genomes, they identified potential genetic determinants of various P. acnes strains in association with acne or health. 

Their analysis suggests that acquired DNA sequences and bacterial immune elements may have roles in determining virulence properties of P. acnes strains, and some could be future targets for therapeutic interventions. This study demonstrates a previously unreported paradigm of commensal strain populations that could explain the pathogenesis of human diseases. It underscores the importance of strain-level analysis of the human microbiome to define the role of commensals in health and disease.

Comment: These results show that Propionibacterium 'rules the skin' in the oily skin of young persons, whether or not they have acne. What is striking is the absence of Staph aureus and Strep species from the skin microbiome of these subjects, suggesting the possibility that the resident bacteria may have a 'probiotic' effect. Also of note is the fact that the normal skin flora  (Propionibacterium Acnes, Propionibacterium humerusii, Propionibacterium granulosum and Staph Epidermidis and Staph Capitis) have all been recovered from deep cultures of shoulders having revision of failed arthroplasty. These observations leave us with the question "is it a good idea to remove the Propionibacterium from the local skin of candidates for shoulder arthroplasty?"

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Propionibacterium and the shoulder

Here is a review of some of the important things we think we know about Propionibacterium and the shoulder.

I. It is now recognized that, rather than being a barrier that keeps bacteria out of the body; the skin is a veritable garden containing viruses, fungi, and bacteria (including Propionibacterium). This microbiome varies in different cutaneous ecosystems.  Propionibacterium are particularly prominent in the oily skin of the chest and back (including the areas of incision for shoulder surgery), rather than in the damp axillary area as previously thought. It is possible that the presence of Propionibacterium in the complex  healthy microbiome contributes to the resistance of the shoulder to more aggressive organisms, such as Staph Aureus and Streptococcus.

Belkaid, Y. and J. A. Segre (2014). "Dialogue between skin microbiota and immunity." Science 346(6212): 954-959.

Chehoud, C., et al. (2013). "Complement modulates the cutaneous microbiome and inflammatory milieu." Proc Natl Acad Sci U S A 110(37): 15061-15066.

Chen, Y. E. and H. Tsao (2013). "The skin microbiome: current perspectives and future challenges." J Am Acad Dermatol 69(1): 143-155.

Findley, K., et al. (2013). "Topographic diversity of fungal and bacterial communities in human skin." Nature 498(7454): 367-370.

Grice, E. A. (2014). "The skin microbiome: potential for novel diagnostic and therapeutic approaches to cutaneous disease." Semin Cutan Med Surg 33(2): 98-103.

Grice, E. A., et al. (2009). "Topographical and temporal diversity of the human skin microbiome." Science 324(5931): 1190-1192.

Grice, E. A. and J. A. Segre (2011). "The skin microbiome." Nat Rev Microbiol 9(4): 244-253.

Grice, E. A. and J. A. Segre (2012). "The human microbiome: our second genome." Annu Rev Genomics Hum Genet 13: 151-170.

Grice, E. A., et al. (2008). "A diversity profile of the human skin microbiota." Genome Res 18(7): 1043-1050.

Grice, E. A. and J. A. Segre (2012). "Interaction of the microbiome with the innate immune response in chronic wounds." Adv Exp Med Biol 946: 55-68.

Findley, K. and E. A. Grice (2014). "The skin microbiome: a focus on pathogens and their association with skin disease." PLoS Pathog 10(10): e1004436.

Kong, H. H., et al. (2012). "Temporal shifts in the skin microbiome associated with disease flares and treatment in children with atopic dermatitis." Genome Res 22(5): 850-859.

Misic, A. M., et al. (2014). "The Wound Microbiome: Modern Approaches to Examining the Role of Microorganisms in Impaired Chronic Wound Healing." Adv Wound Care (New Rochelle) 3(7): 502-510.

Naik, S., et al. (2012). "Compartmentalized control of skin immunity by resident commensals." Science 337(6098): 1115-1119.

Nakatsuji, T., et al. (2013). "The microbiome extends to subepidermal compartments of normal skin." Nat Commun 4: 1431.

Oh, J., et al. (2014). "Biogeography and individuality shape function in the human skin metagenome." Nature 514(7520): 59-64.

Patel, A., et al. (2009). "Propionibacterium acnes colonization of the human shoulder." J Shoulder Elbow Surg 18(6): 897-902.

SanMiguel, A. and E. A. Grice (2014). "Interactions between host factors and the skin microbiome." Cell Mol Life Sci.

II. Propionibacterium has the ability to form a biofilm on hair follicles, metal and plastic implants and on suture, enabling it to durably resist host defenses and antibiotics and to live in a relatively anaerobic environment from which it can exert its effects on bone resorption (osteolysis) and joint stiffness over months and years.

Achermann, Y., et al. (2014). "Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen." Clin Microbiol Rev 27(3): 419-440.

Al-Ahmad, A., et al. (2014). "Antibiotic resistance and capacity for biofilm formation of different bacteria isolated from endodontic infections associated with root-filled teeth." J Endod 40(2): 223-230.

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

Bayston, R., et al. (2007). "Biofilm formation by Propionibacterium acnes on biomaterials in vitro and in vivo: impact on diagnosis and treatment." J Biomed Mater Res A 81(3): 705-709.

Bayston, R., et al. (2007). "Antibiotics for the eradication of Propionibacterium acnes biofilms in surgical infection." J Antimicrob Chemother 60(6): 1298-1301.

Coenye, T., et al. (2007). "Biofilm formation by Propionibacterium acnes is associated with increased resistance to antimicrobial agents and increased production of putative virulence factors." Res Microbiol 158(4): 386-392.

Furustrand Tafin, U., et al. (2012). "Role of rifampin against Propionibacterium acnes biofilm in vitro and in an experimental foreign-body infection model." Antimicrob Agents Chemother 56(4): 1885-1891.

Jahns, A. C. and O. A. Alexeyev (2014). "Three dimensional distribution of Propionibacterium acnes biofilms in human skin." Exp Dermatol 23(9): 687-689.

Portillo, M. E., et al. (2013). "Propionibacterium acnes: an underestimated pathogen in implant-associated infections." Biomed Res Int 2013: 804391.

Ramage, G., et al. (2003). "Formation of Propionibacterium acnes biofilms on orthopaedic biomaterials and their susceptibility to antimicrobials." Biomaterials 24(19): 3221-3227.

Sampedro, M. F., et al. (2010). "A biofilm approach to detect bacteria on removed spinal implants." Spine (Phila Pa 1976) 35(12): 1218-1224.

Tebruegge, M., et al. (2014). "Invasive Propionibacterium acnes infections in a non-selective patient cohort: clinical manifestations, management and outcome." Eur J Clin Microbiol Infect Dis.

Tunney, M. M., et al. (2007). "Biofilm formation by bacteria isolated from retrieved failed prosthetic hip implants in an in vitro model of hip arthroplasty antibiotic prophylaxis." J Orthop Res 25(1): 2-10.

Tunney, M. M., et al. (1999). "Detection of prosthetic hip infection at revision arthroplasty by immunofluorescence microscopy and PCR amplification of the bacterial 16S rRNA gene." J Clin Microbiol 37(10): 3281-3290.

III. Propionibacterium in surgical wounds may originate from the dermis, which is not sterilized by surgical skin preparation.

Matsen, F. A., 3rd, et al. (2013). "Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites." J Bone Joint Surg Am 95(23): e1811-1817.

Lee, M. J., et al. (2014). "Propionibacterium persists in the skin despite standard surgical preparation." J Bone Joint Surg Am 96(17): 1447-1450.

IV. Propionibacterium can recovered from shoulders without prior surgery.  It is not clear if these organisms are seeded from the overlying dermis or hematogenously from distant sources, such as the mouth.

Bunker, T., et al (2014) “Association between Propionibacterium acnes and frozen shoulder: a pilot study.” Shoulder & Elbow October 2014 vol. 6 no. 4 257-261

Hudek, R., et al. (2014). "Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?" J Shoulder Elbow Surg 23(12): 1763-1771.

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

Matsen, F. A., 3rd, et al. (2014). "Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis." J Shoulder Elbow Surg. Published Online: December 26, 2014

Schaeverbeke, T., et al. (1998). "Propionibacterium acnes isolated from synovial tissue and fluid in a patient with oligoarthritis associated with acne and pustulosis." Arthritis Rheum 41(10): 1889-1893.

Sethi, P. M., et al. (2014). "Presence of Propionibacterium acnes in primary shoulder arthroscopy: results of aspiration and tissue cultures." J Shoulder Elbow Surg.

V. In the past the presence of Propionibacterium in failed shoulder arthroplasty has probably been overlooked because appropriate number and type of specimens were not taken and because the necessary culturing methods were not used when revision shoulder arthroplasty was performed in cases of prosthetic failure without clinical evidence of infection (such as apparently aseptic loosening of the glenoid).

Butler-Wu, S. M., et al. (2011). "Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection." J Clin Microbiol 49(7): 2490-2495.

Matsen, F. A., 3rd, et al. (2013). "Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites." J Bone Joint Surg Am 95(23): e1811-1817.

Pottinger, P., et al. (2012). "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 94(22): 2075-2083.

Schafer, P., et al. (2008). "Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy." Clin Infect Dis 47(11): 1403-1409.

Tebruegge, M., et al. (2014). "Invasive Propionibacterium acnes infections in a non-selective patient cohort: clinical manifestations, management and outcome." Eur J Clin Microbiol Infect Dis.

VI. Not all the Propionibacterium recovered from failed arthroplasties are P. Acnes

Butler-Wu, S. M., et al. (2011). "Genome sequence of a novel species, Propionibacterium humerusii." J Bacteriol 193(14): 3678.

VII. Propionibacterium was isolated from failed arthroplasties without clinical evidence of infection as early as 2007. Subsequently there have been many reports of the recovery of Propionibacterium from failed shoulder surgeries. It appears that almost half of failed arthroplasties are culture positive for Propionibacterium. In that the role of Propionibacterium in prosthetic failure remains to be clarified, it is preferable to speak of the culture results, rather than trying to come up with a definition of  ‘true infection’. Speaking of the number of positive cultures is not meaningful without indicating the source and number of specimens submitted and how they were cultured. Thus the preferred terminology is ‘failed arthroplasty with 4 out of 5 tissue and explant positive for Propionibacterium-specific cultures’.

Franta, A. K., et al. (2007). "The complex characteristics of 282 unsatisfactory shoulder arthroplasties." J Shoulder Elbow Surg 16(5): 555-562.

Achermann, Y., et al. (2014). "Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen." Clin Microbiol Rev 27(3): 419-440.

Achermann, Y., et al. (2013). "Characteristics and outcome of 16 periprosthetic shoulder joint infections." Infection 41(3): 613-620.

Achermann, Y., et al. (2010). "Improved diagnosis of periprosthetic joint infection by multiplex PCR of sonication fluid from removed implants." J Clin Microbiol 48(4): 1208-1214.

Athwal, G. S., et al. (2007). "Deep infection after rotator cuff repair." J Shoulder Elbow Surg 16(3): 306-311.

Athwal, G. S., et al. (2007). "Acute deep infection after surgical fixation of proximal humeral fractures." J Shoulder Elbow Surg 16(4): 408-412.

Beekman, P. D., et al. (2010). "One-stage revision for patients with a chronically infected reverse total shoulder replacement." J Bone Joint Surg Br 92(6): 817-822.

Berthelot, P., et al. (2006). "Outbreak of postoperative shoulder arthritis due to Propionibacterium acnes infection in nondebilitated patients." Infect Control Hosp Epidemiol 27(9): 987-990.

Bonnevialle, N., et al. (2010). "Bilateral clavicle fracture external fixation." Orthop Traumatol Surg Res 96(7): 821-824.

Cheung, E. V., et al. (2007). "Reimplantation of a glenoid component following component removal and allogenic bone-grafting." J Bone Joint Surg Am 89(8): 1777-1783.

Cheung, E. V., et al. (2008). "Revision shoulder arthroplasty for glenoid component loosening." J Shoulder Elbow Surg 17(3): 371-375.

Cheung, E. V., et al. (2008). "Infection associated with hematoma formation after shoulder arthroplasty." Clin Orthop Relat Res 466(6): 1363-1367.

Crane, J. K., et al. (2013). "Antimicrobial susceptibility of Propionibacterium acnes isolates from shoulder surgery." Antimicrob Agents Chemother 57(7): 3424-3426.

Dilisio, M. F., et al. (2014). "Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection." J Bone Joint Surg Am 96(23): 1952-1958.

Dodson, C. C., et al. (2010). "Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge." J Shoulder Elbow Surg 19(2): 303-307.

Erickson, B. J., et al. (2014). "Acute infection with Propionibacterium acnes after a Latarjet coracoid transfer procedure: a case report." Knee Surg Sports Traumatol Arthrosc.

Foruria, A. M., et al. (2013). "Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty." J Shoulder Elbow Surg 22(5): 620-627.

Franceschini, V. and C. Chillemi (2013). "Periprosthetic shoulder infection." Open Orthop J 7: 243-249.

Grosso, M. J., et al. (2012). "Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures." J Shoulder Elbow Surg 21(6): 754-758.

Hattrup, S. J. and K. J. Renfree (2010). "Two-stage shoulder reconstruction for active glenohumeral sepsis." Orthopedics 33(1): 20.

Herrera, M. F., et al. (2002). "Infection after mini-open rotator cuff repair." J Shoulder Elbow Surg 11(6): 605-608.

Horneff, J. G., et al. (2014). "Propionibacterium acnes infections in shoulder surgery." Orthop Clin North Am 45(4): 515-521.

Hou, C. et al “How do revised shoulders that are culture positive for Propionibacterium differ from those that are not?” J Shoulder Elbow Surg 2015.

Ince, A., et al. (2005). "One-stage exchange shoulder arthroplasty for peri-prosthetic infection." J Bone Joint Surg Br 87(6): 814-818.

Kelly, J. D., 2nd and E. R. Hobgood (2009). "Positive culture rate in revision shoulder arthroplasty." Clin Orthop Relat Res 467(9): 2343-2348.

Khassebaf, J., et al. (2014). "Antibiotic susceptibility of Propionibacterium acnes isolated from orthopaedic implant-associated infections." Anaerobe 32C: 57-62.

Kim, S. J. and J. H. Kim (2014). "Unexpected positive cultures including isolation of Propionibacterium acnes in revision shoulder arthroplasty." Chin Med J (Engl) 127(22): 3975-3979.

Klatte, T. O., et al. (2013). "Single-stage revision for peri-prosthetic shoulder infection: outcomes and results." Bone Joint J 95-B(3): 391-395.

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

McGoldrick, E., et al. (2015). "Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty." J Shoulder Elbow Surg 24(1): 31-35.

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