All Propionibacteria are not the same - some are hemolytic and some are drug resistant

Hemolysis Is a Diagnostic Adjuvant for Propionibacterium acnes Orthopaedic Shoulder Infections

These authors explored the pathogenicity of hemolytic and nonhemolytic phenotypes of Propionibacterium acnes (P acnes) isolates from shoulder joint aspiration fluid and/or intraoperative tissues.

Hemolysis demonstrated 100% specificity with a positive predictive value of 100% and 80% sensitivity with a negative predictive value of 73% for determining definite and probable infections. 

100% of the patients in the hemolytic group and only 27% of patients in the nonhemolytic group were classified as infected.

Inflammatory markers were markedly higher in the hemolytic group.

Clindamycin resistance was found in 31% of the hemolytic strains, whereas no antibiotic resistance was observed in the nonhemolytic group. 

Time from index surgery to the initial treatment or revision procedure was almost twice as long in the nonhemolytic group. A substantial percentage of patients in the hemolytic group (44%) compared with the nonhemolytic group (0%) failed initial treatment requiring a revision procedure for persistent infection.

These authors concluded that hemolytic strains of P acnes exhibit enhanced pathogenicity to their host by eliciting a more prominent systemic inflammatory response, increased antibiotic resistance, and a more challenging clinical course. 

Comment: This article needs to be considered along with another recent publication:

Hemolytic strains of Propionibacterium acnes do not demonstrate greater pathogenicity in periprosthetic shoulder infections

Certain strains of Propionibacterium result in hemolysis when streaked on a blood agar plate as shown in "A" below in contrast to "B" which does not show hemolysis.

These authors studied 39 patients with at least 1 positive culture for P acnes at the time of revision shoulder arthroplasty who also had testing of the Propionibacterium for hemolysis. 20 of the isolated strains showed hemolytic activity and 19 did not. 

In this study the presence of hemolysis was not significantly associated with greater clinical evidence of infection. The hemolytic and nonhemolytic groups showed no difference regarding preoperative serum erythrocyte sedimentation rate and/or C-reactive protein level (P = .70), number of positive cultures (P = .395), time to positive culture (P = .302), and presence of positive frozen section findings (P = .501). Postoperatively, clindamycin resistance, shoulder function, and the rate of reoperation were not significantly different between the hemolytic and nonhemolytic groups.

These authors point out that a prior study by Nodzo et al in 2014 demonstrated significantly elevated
CRP levels in hemolysis-positive patients.  More recently, this group expanded their analysis with 31 patients evaluated for hemolysis. In that study by Boyle et al 2016 showed significantly elevated ESR and CRP levels, as well as a significantly greater percentage (31% vs 0%) of antibiotic resistance, in cases with hemolysis-positive Propionibacterium cultures.

Comment: At this point it is difficult to be sure whether or not hemolytic strains are more virulent than non-hemolytic strains of Propionibacterium.  It is clear, however, that all strains of Propionibacterium are not the same as revealed by the hemolytic phenotype as well as the Clindamycin-resistant phenotype. How these differences affect the diagnosis, clinical course and management of Propionibacterium in revision arthroplasty remains to be seen.

Interested readers may be interested in these two articles:

Genetic profiles of Propionibacterium acnes and identification of a unique transposon with novel insertion sequences in sarcoid and non-sarcoid isolates  which identified two hemolytic-associated genes (camp 5 and tly) and

Enzymatic and hemolytic properties of Propionibacterium acnes and related bacteria.

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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.

How you can support progress in shoulder surgery

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'

Propionibacterium are becoming antibiotic resistant. Dermatologists have resistant forms.

Recent advances in understanding Propionibacterium acnes (Cutibacterium acnes) in acne

The skin commensal Propionibacterium acnes, recently renamed Cutibacterium acnes, along with the other major pathophysiological factors of increased seborrhea, hyperkeratinization of the pilosebaceous unit, and inflammation, has long been implicated in the pathogenesis of acne. 

Recent advances have contributed to our understanding of the role of P. acnes in acne. Although there are no quantitative differences in P. acnes of the skin of patients with acne compared with controls, the P. acnes phylogenic groups display distinct genetic and phenotypic characteristics.

P. acnes biofilms are more frequent in acne, and different phylotypes may induce distinct immune responses in acne. 

P. acnes plays a further important role in the homeostasis of the skin’s microbiome, interacting with other cutaneous commensal or pathogenic microorganisms such as Staphylococcus epidermidis, Streptococcus pyogenes, and Pseudomonas species. 

In the era of increasing antimicrobial resistance, the selection of acne treatment targeting P. acnes and the prevention of antibiotic resistance play a key role in improving outcomes in acne patients and public health.
The antibiotic resistance (to clindamycin, tetracycline, and erythromycin) of P. acnes is a worldwide problem, and rates of resistance increased from 20% in 1979 to 64% in 2000.

A study of 664 patients in the UK, Spain, Italy, Greece, Sweden, and Hungary reported that the prevalence of P. acnes resistance rates ranged from 50.8% to 93.6% to any antibiotic (tetracycline, macrolide, lincosamide, and streptogramin B).

All dermatologists who specialized in treating acne were colonized with resistant Propionibacteria.

The widespread use of antibiotics to treat acne may result in the development of P. acnes strains with cross-resistance to different antibiotics and have possible implications in acne and other diseases, such as periprosthetic infections.

Propionibacterium acnes and bacterial resistance

In this review article, the authors point out that Propionibacterium acnes is one of the main microorganisms found on the skin. It is predominantly found in hair follicles, prefers anaerobic conditions, preferably colonizes the areas with high sebum production, and is the main bacterium involved in the pathogenesis of acne. They suggest that the indiscriminate use of antibiotics for the treatment of acne vulgaris can result in the development of bacterial resistance.

Several observations in this article are of interest to us shoulder surgeons:

There are over one million Propionibacterium per square centimeter of skin.

Propionibacterium inhibits the invasion of the skin by common pathogens such as Staphylococcus aureus and Streptococcus pyogenes.  Its hydrolyzation of triglycerides with the release of free fatty acids (including propionic acid) contributes to the acid pH of the skin’s surface, which is another factor for skin protection. Note: this suggests that elimination of Propionibacterium from the skin of the surgical site may open the door for worse bugs.

There are many different types of Propionibacterium; on average, each individual has 3 different Propi ribotypes on the skin each with different pathogen potential and different resistance patterns. 

Persons can transmit the different clones to other individuals, and thus resistant bacteria can be spread throughout the population by 'rubbing elbows'.

There has been an increasing number of cases of antibiotic- resistance by P. acnes over the years: in the UK, the resistance rate increased from 34.5% in 1991 to 55.5% in 2000;156 94% of  the isolates in Spain and 51% from the isolates in Hungary were  resistant to at least one antibiotic. The highest resistance rates are related to erythromycin, with cross-resistance to clindamycin. The lowest resistance rates are to tetracyclines.

Resistance comes from gene mutation:

In cases of severe infections caused by P. acnes, surgical procedures should be combined with crystalline penicillin, vancomycin, daptomycin, and rifampicin due to their effect on the biofilm.

 The reasons for the emergence of Propionibacterium as a problem in shoulder surgery is becoming clearer - the use of antibiotics for acne and for other reasons is changing the genetics of the bacterium to favor antibiotic resistance and the resistant strains are being exchanged within the human population.

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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.

How you can support progress in shoulder surgery

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'

Propionibacterium - be aware, drug resistance is coming!

Antimicrobial susceptibility and phylogenetic analysis of Propionibacterium acnes isolated from acne patients in Japan between 2013 and 2015


These authors note that the prevalence of antimicrobial-resistant Propionibacterium acnes strains isolated from acne patients has been increasing. They tested antimicrobial susceptibility among P. acnes from acne patients visiting a specialized dermatology clinic between 2013 and 2015. 

Rates of resistance to macrolides (e.g. Azithromycin, Erythromycin) and clindamycin were 44.3 (31/70) and 38.6% (27/70), respectively. 

The erm(X) gene, which confers high-level clindamycin resistance was detected in six isolates (single-locus sequence type clades A, E, F, H and K), 

No resistance determinants were identified in eight strains (clade F) showing high-level resistance to clindamycin. Strains of clade F, which were very rarely isolated from healthy individuals, were more frequently recovered from patients with severe acne (40.0%) than those with mild acne (23.3%).

P. acnes isolates from patients previously treated with macrolides and clindamycin showed a macrolide resistance rate (55.3%) significantly higher than that of those from patients not having received these treatments (21.7%, P < 0.05). 

They concluded that there was an increase in macrolide-resistant P. acnes prevalence  due to the use of antimicrobial agents for acne treatment. 

The Propionibacterium in this study were sensitive to Amoxicillin and tetracyclines.

Comment: While (as shown by the chart below) patients with acne are much younger than those at risk for shoulder periprosthetic infections, 

we know that bacteria are shared among individuals by direct and indirect contact (see below)

Microbiota bacteriana asociada al papel moneda de circulación en Colombia

Commonly used objects such as currency paper can be colonised by bacteria and can serve as carriers of microbes. This colonisation might expose us to unnoticed pathogenic bacteria. In this study, the researchers obtained a detailed panorama of the microbes that can be carried on currency notes in Colombia by using 454 next-generation deep sequencing of 16S amplicón libraries. A total of 233 bacterial genera were detected and classified, 12 of which are potential human pathogens. The most abundant genera were Propionibacterium, Streptococcus, Staphylococcus and Pseudomonas. To date, this is the first in-depth analysis of the microbiota carried by circulating banknotes in our continent and it offers insights into daily exposure to microbes when using banknotes in Colombia.

The same must hold true for the currencies of all countries.

For the historical reference to 'follow the money' see this link.

Comment: This important study complements other evidence that Propionibacterium, including drug resistant strains, can be easily passed from one person to another. See: Propionibacterium acnes and bacterial resistance

In this review article, the authors point out that Propionibacterium acnes is one of the main microorganisms found on the skin. It is predominantly found in hair follicles, prefers anaerobic conditions, preferably colonizes the areas with high sebum production, and is the main bacterium involved in the pathogenesis of acne. They suggest that the indiscriminate use of antibiotics for the treatment of acne vulgaris can result in the development of bacterial resistance.

Several observations in this article are of interest to us shoulder surgeons:

There are over one million Propionibacterium per square centimeter of skin.

Propionibacterium inhibits the invasion of the skin by common pathogens such as Staphylococcus aureus and Streptococcus pyogenes.  Its hydrolyzation of triglycerides with the release of free fatty acids (including propionic acid) contributes to the acid pH of the skin’s surface, which is another factor for skin protection. Note: this suggests that elimination of Propionibacterium from the skin of the surgical site may open the door for worse bugs.

There are many different types of Propionibacterium; on average, each individual has 3 different Propi ribotypes on the skin each with different pathogen potential and different resistance patterns. 

Persons can transmit the different clones to other individuals, and thus resistant bacteria can be spread throughout the population by 'rubbing elbows'.

There has been an increasing number of cases of antibiotic- resistance by P. acnes over the years: in the UK, the resistance rate increased from 34.5% in 1991 to 55.5% in 2000;156 94% of  the isolates in Spain and 51% from the isolates in Hungary were  resistant to at least one antibiotic. The highest resistance rates are related to erythromycin, with cross-resistance to clindamycin. 

Resistance comes from gene mutation:

In cases of severe infections caused by P. acnes, surgical procedures should be combined with crystalline penicillin, vancomycin, daptomycin, and rifampicin due to their effect on the biofilm.

The reasons for the emergence of Propionibacterium as a problem in shoulder surgery is becoming clearer - the use of antibiotics for acne and for other reasons is changing the genetics of the bacterium to favor antibiotic resistance and the resistant strains are being exchanged within the human population.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Propionibacterium - resistance to tetracyclines

Propionibacterium acnes is developing gradual increase in resistance to oral tetracyclines

These authors point out that, while tetracylines are often used to treat Propionibacterium infections,  many tetracycline-resistant P. acnes strains have been isolated in part due to the frequent use of oral tetracycline is frequently used as an acne treatment.

They report a novel tetracycline resistance mechanism in P. acnes. They isolated three doxycycline-resistant strains and six strains that had reduced susceptibility compared to susceptible strains.

All doxycycline-resistant strains had a G1058C mutation in the 16S rRNA gene in addition to an amino acid substitution in the ribosomal S10 protein encoded by rpsJ. Their results show that the S10 protein amino acid substitution contributes to reduced doxycycline susceptibility in P. acnes and suggests that tetracyclines resistance is acquired through a 16S rRNA mutation after the S10 protein amino acid substitution.

Comment: There is no question that Propionibacterium are acquire resistance to Clindamycin and to tetracyclines. Currently, it is not common practice to obtain sensitivities on Propi cultures, but it may be time for this practice to change.

Of note is another recent article:
Antimicrobial activity of topical agents against Propionibacterium acnes: an in vitro study of clinical isolates from a hospital in Shanghai, China

These authors determined the susceptibilities of Propionibacterium to clindamycin and erythromycin The resistance rates to neomycin sulfate, erythromycin, and clindamycin were 11.7%, 49.3%, and 33.4%, respectively. 

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Propionibacterium antibiotic resistance - more bad news

Propionibacterium acnes and bacterial resistance

In this review article, the authors point out that Propionibacterium acnes is one of the main microorganisms found on the skin. It is predominantly found in hair follicles, prefers anaerobic conditions, preferably colonizes the areas with high sebum production, and is the main bacterium involved in the pathogenesis of acne. They suggest that the indiscriminate use of antibiotics for the treatment of acne vulgaris can result in the development of bacterial resistance.

Several observations in this article are of interest to us shoulder surgeons:

There are over one million Propionibacterium per square centimeter of skin.

Propionibacterium inhibits the invasion of the skin by common pathogens such as Staphylococcus aureus and Streptococcus pyogenes.  Its hydrolyzation of triglycerides with the release of free fatty acids (including propionic acid) contributes to the acid pH of the skin’s surface, which is another factor for skin protection. Note: this suggests that elimination of Propionibacterium from the skin of the surgical site may open the door for worse bugs.

There are many different types of Propionibacterium; on average, each individual has 3 different Propi ribotypes on the skin each with different pathogen potential and different resistance patterns. 

Persons can transmit the different clones to other individuals, and thus resistant bacteria can be spread throughout the population by 'rubbing elbows'.

There has been an increasing number of cases of antibiotic- resistance by P. acnes over the years: in the UK, the resistance rate increased from 34.5% in 1991 to 55.5% in 2000;156 94% of  the isolates in Spain and 51% from the isolates in Hungary were  resistant to at least one antibiotic. The highest resistance rates are related to erythromycin, with cross-resistance to clindamycin. The lowest resistance rates are to tetracyclines.

Resistance comes from gene mutation:

In cases of severe infections caused by P. acnes, surgical procedures should be combined with crystalline penicillin, vancomycin, daptomycin, and rifampicin due to their effect on the biofilm.

Comment: The reasons for the emergence of Propionibacterium as a problem in shoulder surgery is becoming clearer - the use of antibiotics for acne and for other reasons is changing the genetics of the bacterium to favor antibiotic resistance and the resistant strains are being exchanged within the human population.

====

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.