Articles were included in this review if they (1) had a clear objective of investigating the effectiveness of a home prophylactic measure prior to shoulder surgery, (2) reported a primary outcome of skin surface culture positivity or diagnosis of infection with Cutibacterium, and (3) were in the English language.
Chlorhexidine can be administered in a variety of formulations, including infused cloths or a topical solution with concentrations ranging from 2% to 4%. On the other hand, BPO can be administered as a 5% gel or applied as an emollient foam. In each of the evaluated studies, BPO was consistently applied preoperatively in gel form.
Chlorhexidine, with or without isopropyl alcohol, is a broad-spectrum antiseptic effective against most grampositive and gram-negative bacteria and fungi and exhibits both bacteriostatic and bactericidal activity.
BPO functions as an antimicrobial agent that is toxic to ductal bacteria because its lipophilic structure allows it to penetrate into the pilosebaceous glands. Once it has entered, it decomposes to release free radicals to eradicate bacteria in sebaceous follicles.
BPO treatment resulted in a significantly lower rate of culture positivity (17%) compared with chlorhexidine treatment (37%, p , 0.00001).
As none of the studies reported infections, the authors could not compare the effectiveness of the preparations in reducing infection rates. There were insufficient data available to compare adverse reactions from the use of BPO and Chlorhexidine.
Comment: This is an important area of study, in that Cutibacterium periprosthetic infections (PJI) are a major issue in shoulder arthroplasty. Young male patients are known to be at increased risk. Thus it would be of interest to see a comparison of these two preparations in that higher risk population. Currently, it is possible to assess the load of bacteria culture specimens, so it would be of interest to know the effect of these two agents on the amount of bacteria in the specimen (not just the presence or absence).
Finally, it is of interest that neither agent was completely successful in eliminating Cutibacterium from the skin cultures. This points to the fact that a multimodal approach to reducing the chance of Cutibacterium PJI is needed - especially in patients at high risk - including preoperative skin treatment, intraoperative measures (e.g. irrigation, Betadine lavage, topical antibiotics, etc), and consideration of a short course of postoperative antibiotics.
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