Justin D. Stull, MD, Thema A. Nicholson, MS, Daniel E. Davis, MD, MS, Surena Namdari, MD, MSc

J Shoulder Elbow Surg. 2020 Feb;29(2):212-216
https://doi.org/10.1016/j.jse.2019.09.038

Summary by Michael Gutman, BA

Cutibacterium acnes (C. acnes), an anaerobic bacterium, is the most common organism responsible for postoperative infection after shoulder surgery. ^1-3 C. acnes is more commonly found in the dermal layer of the shoulder than any other joint of the body. In general, men have a higher bacterial burden of this organism than women, with 70% of males having a positive punch biopsy for C. acnes after sterile surgical preparation.⁴ Recent studies have attempted to decrease the bacterial burden of C. acnes in males.^5,6 Peroxide, in the form of benzoyl peroxide, can decolonize the skin of C. acnes when applied preoperatively for three days.⁶ However, this requires patient compliance and must be initiated prior to surgery.

Stull et al. sought to determine if 3% hydrogen peroxide, in addition to standard sterile surgical preparation, decreased the incidence of positive dermal cultures of C. acnes. In a randomized controlled trial, 140 patients undergoing arthroscopic shoulder surgery received standard surgical preparation alone (n=70; control group) or standard surgical preparation with the addition of five gauzes soaked in 3% hydrogen peroxide (n=70; intervention group). Biopsy samples were acquired prior to the first surgical incision via a 3mm punch at the posterior arthroscopic portal site. In the intervention group, the bacterial culture rate of C. acnes decreased by 50% compared to the control group (17.1% vs. 34.2%, P=0.033). The authors successfully demonstrated that 3% hydrogen peroxide could be used safely and efficaciously during the surgical preparation period to decolonize the skin of C. acnes.

This study is not without its limitations. There is the potential for contamination affecting the results of the study. Additionally, while standard surgical preparation was applied thoroughly to all patients, there was no protocol regarding the length of time standard surgical preparation was performed for each patient.

References:

1. Horneff JG, Hsu JE, Voleti PB, O’Donnell J, Huffman GR. Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J. Shoulder Elb. Surg. 2015;doi:10.1016/j.jse.2015.03.008
2. Moen TC, Rudolph GH, Caswell K, Espinoza C, Burkhead WZ, Krishnan SG. Complications of shoulder arthroscopy. J. Am. Acad. Orthop. Surg. 2014;doi:10.5435/JAAOS-22-07-41
3. Saltzman MD, Marecek GS, Edwards SL, Kalainov DM. Infection after shoulder surgery. J. Am. Acad. Orthop. Surg. 2011;doi:10.5435/00124635-201104000-00005
4. Lee MJ, Pottinger PS, Butler-Wu S, Bumgarner RE, Russ SM, Matsen FA. Propionibacterium persists in the skin despite standard surgical preparation. J. Bone Jt. Surg. – Am. Vol. 2014;doi:10.2106/JBJS.M.01474
5. Dizay HH, Lau DG, Nottage WM. Benzoyl peroxide and clindamycin topical skin preparation decreases Propionibacterium acnes colonization in shoulder arthroscopy. J. Shoulder Elb. Surg. 2017;doi:10.1016/j.jse.2017.03.003
6. Kolakowski L, Lai JK, Duvall GT, Jauregui JJ, Dubina AG, Jones DL, et al. Neer Award 2018: Benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial. J. Shoulder Elb. Surg. 2018;doi:10.1016/j.jse.2018.06.012