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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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
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). 

Safety and efficacy of benzoyl peroxide, blue light and chlorhexidine in Cutibacterium prophylaxis

 Efficacy of Combinational Therapy Using Blue Light and Benzoyl Peroxide in Reducing Cutibacterium Acnes Bioburden at the Deltopectoral Interval: A Randomized Controlled Trial

These authors compared the efficacy of blue light therapy (BLT) and 5% topical benzoyl peroxide (BPO) gel in combination with standard chlorhexidine (CHX) prep in eradicating Cutibacterium on the skin surface at the deltopectoral interval measured by positive, quantitative cultures.

Adult male volunteers were randomized to one of three treatment groups: BPO, BLT, and BPO followed by BLT. Contralateral shoulders served as matched controls. Volunteers randomized to BPO applied the gel for a total of 5 treatments. For BLT group, a single 23- minute treatment was administered at an estimated irradiance of 40 mW/cm2 (radiant exposure 55.2 J/cm2).

 For BPO+BLT group, volunteers received both treatments. After treatment with either BPO, BLT, or both, a single swab culture was taken from the skin of the treatment shoulder. Next, control and treatment shoulders were prepped with CHX, and cultures were taken from each shoulder. 

Sixty male volunteers, 20 per group. Prior to CHX administration, 56 of the 60 samples grew Cutibacterium. 

The  BPO group and BPO+BLT group had significantly less growth of Cutibacterium than the BLT group after treatment but prior to CHX. 

Following CHX administration, BPO and BPO+BLT groups had significantly fewer positive cultures  and less quantity of growth compared to their control arms. This was not seen in BLT group. 

For quantitative between group analysis, no significant synergistic effects were seen in the BPO+BLT group compared to BPO only. 

The authors concluded that blue light therapy alone did not demonstrate effective antimicrobial properties against Cutibacterium. 

Comment: 

(1) An important lesson from this study is that a substantial percentage of subjects receiving prophylaxis experienced side effects (itching, burning, dryness, peeling, flaking, erythema) that would create a concern about making a skin incision for shoulder arthroplasty through the treated area. Six out of the 20 subjects in each group reported at least 1 side effect within 1 week of treatment. These treatments may not be benign. 

(2) The skin surface cultures were obtained soon after the application of CHX. Prior studies have shown that the prophylactic effect of CHX subsides rapidly after application.

(3) This study does not examine the effectiveness of prophylaxis on the levels of Cutibacterium in the dermis. It is the dermal levels that are of concern in that the pilosebaceous units are the reservoir for Cutibacterium; the dermal incision at arthroplasty releases Cutibacterium into the wound.

See the study below:Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients

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 (BPO) 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 in patients undergoing shoulder arthroplasty surgery in reducing Cutibacterium levels on the skin surface and in the dermis. 

50 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) used to wash the operative shoulder the night prior and morning of surgery. 

Skin swabs prior to incision and swabs of the dermis incised after standard skin preparation and preoperative IV antibiotics were obtained, and the bacterial load was reported in a semiquantitative manner as the Specimen Cutibacterium Value (SpCuV). 

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 Cutibacterium load (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). 

The authors concluded that neither BPO soap nor chlorhexidine washes prior to shoulder surgery were effective in eliminating Cutibacterium from the skin surface or the incised dermal edge. 

Follow on twitter: https://twitter.com/shoulderarth

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Home Prophylaxis with Benzoyl Peroxide or Chlorhexidine in Shoulder Surgery

 Efficacy of Home Prophylactic Benzoyl Peroxide and Chlorhexidine in Shoulder Surgery.A Systematic Review and Meta-Analysis

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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Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link. Also see the essentials of the ream and run.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery 

Which is best for removing Cutibacterium from the skin, Chlohexidine or Benzoyl Peroxide?

Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients

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 (BPO) 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 in patients undergoing shoulder arthroplasty surgery in reducing Cutibacterium levels on the skin surface and in the dermis. 

50 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) used to wash the operative shoulder the night prior and morning of surgery. 

Skin swabs prior to incision and swabs of the dermis incised after standard skin preparation and preoperative IV antibiotics were obtained, and the bacterial load was reported in a semiquantitative manner as the Specimen Cutibacterium Value (SpCuV). 

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 Cutibacterium load (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). 

The authors concluded that neither BPO soap nor chlorhexidine washes prior to shoulder surgery were effective in eliminating Cutibacterium from the skin surface or the incised dermal edge.

Comment: It is of great concern that neither preoperative wash coupled with standard skin preparation and IV antibiotics were effective in eliminating Cutibacterium - the most common organism to cause periprosthetic infections of the shoulder - from the incised dermis. This suggest that many arthroplasty incisions are contaminated by this organism and that this contamination may be best managed by such means as Betadine irrigation and topical in-wound antibiotics.

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To see a YouTube of on how we do total shoulder arthroplasty, click on this link.

To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

How can Cutibacterium periprosthetic infections be prevented?

Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulderarthroplasty patients

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.

===

How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'