These authors point out that home chlorhexidine washes prior to shoulder surgery are commonly used in an attempt to reduce the skin bacterial load. However, recent studies have suggested that this agent is relatively ineffective against Cutibacterium acne.
Benzoyl peroxide soap is a treatment for acne, but evidence regarding its effectiveness as prophylaxis in shoulder surgery is lacking.
The objective of their study was to compare the effectiveness of home chlorhexidine washes with benzoyl peroxide soap (BPO) in patients undergoing shoulder arthroplasty surgery in reducing Cutibacterium levels on the skin surface and in the dermis freshly incised at shoulder arthroplasty.
Fifty male patients planning to undergo shoulder arthroplasty were consented to be randomized into treatment with 4% chlorhexidine solution (CHG) or 10% benzoyl peroxide soap (BPO) as a wash of the operative shoulder the night prior and morning of surgery.
The patients were basically healthy and good medical candidates for elective arthroplasty.
In the operating room, the unprepared, unshaved skin surface was sampled with a swab in the area of the planned incision.
The skin was then prepared with dual application of 2% CHG in 70% isopropyl alcohol and administration of intravenous antibiotics. Immediately after skin incision, swabs of the dermal wound edge were obtained in a similar fashion to the skin surface.
The bacterial load for each specimen was reported in a semiquantitative manner as the Specimen Cutibacterium Value (SpCuV). The two groups were compared with regards to the percent positivity of the skin surface and incised dermal edge as well as the bacterial load at each site.Skin surface swabs were positive in 100% of patients using CHG and 100% of patients using BPO soap.
The Cutibacterium load (SpCuV) on the skin surface was similar between the two groups (CHG 1.6 ± 1.1 vs. BPO 1.5 ± 1.4, p =0.681).
The percentages of dermal cultures that were positive were not significantly different between the two groups (CHG 61% vs BPO 46%, p = 0.369).
The Cutibacteriumload (SpCuV) on the incised dermal edge was similar between the two groups (CHG 0.8 ± 1.0 vs. BPO 0.8 ± 1.4, p = 0.991).
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Comment: This important randomized control trial demonstrates that neither BPO soap nor chlorhexidine washes prior to shoulder surgery combined with standard skin preparation, draping, and perioperative antibiotics were effective in eliminating Cutibacterium from the skin surface or the incised dermal edge. This means that in many cases of elective shoulder arthroplasty in male patients, Cutibacterium is introduced into the arthroplasty wound. Unless this inoculation is successfully removed by a combination of surgical technique (such as irrigation and topical antibiotics) and host defenses, the arthroplasty is at risk for a periprosthetic infection.
We conclude that a rationale approach to preventing Cutibacterium periprosthetic infections combines (1) identification of patients at high risk, (2) consideration of adjunctive measures, such as Betadine lavage, topical in-wound antibiotics, postoperative antibiotics, and (3) close monitoring of patients for unexpected pain and stiffness.
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