Paper of the Week: Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial

Gagan Grewal MD, Teja Polisetty BS, Andrew Boltuch DO, Ryan Colley DO, Raul Tapia MD, Jonathan C. Levy MD

Journal of Shoulder and Elbow Surgery (Volume 30, Issue 8, August 2021, Pages 1827-1833)
DOI: https://doi.org/10.1016/j.jse.2021.03.144

Summary by Anya T. Hall, BS

Cutibacterium acnes is an anaerobic, lipophilic bacterium that is the most commonly identified cause of periprosthetic shoulder joint infection (PJI).¹ PJI after shoulder arthroplasty is a major source of morbidity and is the most common cause of revision arthroplasty within 2 years.² Previous studies have attempted to identify methods to reduce the prevalence of C acnes at the surgical site,^3,4 but there is reason to believe that the efficacy of topical antiseptics may be limited due to the high concentration of sebaceous glands within the dermis.⁵

The purpose of this study was to determine whether the application of hydrogen peroxide to the dermis after incision affects the incidence of positive C acnes cultures during shoulder arthroplasty. Sixty patients undergoing primary anatomic shoulder arthroplasty, reverse shoulder arthroplasty, or hemiarthroplasty by a single surgeon from February 2020 to November 2020 were enrolled. Patients were randomized to receive standard skin preparation and antibiotic prophylaxis either with or without an additional application of hydrogen peroxide to the dermis following incision. The primary outcomes were dermis culture, skin culture, glenohumeral joint culture, and operating room air culture.

The overall rate of at least 1 positive culture was 18% (all C acnes). There were no positive cultures in the joint or air. The rate of positive cultures was similar between the skin and dermis (P>0.99). The positive culture rate was similar between the hydrogen peroxide group (20%) and the control group (16%, P>0.99). Patients with positive cultures were younger in age (67.5 ± 8.4 vs. 73.3 ± 8.3; P=0.038) and more likely to be male (91% vs. 39%, P=0.002) than patients with negative cultures. There were no wound complications in either study group. 

The authors concluded that standard skin preparation and antibiotic prophylaxis result in low rates of positive skin and dermis culture during shoulder arthroplasty. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C acnes cultures and did not result in wound complications. Limitations of this study include an older patient population with a mean age of 72 years, compared to the mean age of 51 years in previous studies examining surgical site infections after shoulder arthroplasty. Another limitation is that the laboratory used biochemical assays for bacterial identification rather than mass spectrometry, which may limit this study’s external validity.

References:

1. Dizay, Hailey H., Diana G. Lau, and Wesley M. Nottage. “Benzoyl peroxide and clindamycin topical skin preparation decreases Propionibacterium acnes colonization in shoulder arthroscopy.” Journal of shoulder and elbow surgery 26.7 (2017): 1190-1195.
2. Portillo, María Eugenia, et al. “Prosthesis failure within 2 years of implantation is highly predictive of infection.” Clinical Orthopaedics and Related Research® 471.11 (2013): 3672-3678.
3. Chalmers, Peter N., et al. “Hydrogen peroxide skin preparation reduces Cutibacterium acnes in shoulder arthroplasty: a prospective, blinded, controlled trial.” Journal of shoulder and elbow surgery 28.8 (2019): 1554-1561.
4. Kolakowski, Logan, et al. “Neer Award 2018: benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial.” Journal of shoulder and elbow surgery 27.9 (2018): 1539-1544.
5. Stull, Justin D., et al. “Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes–positive culture rate in shoulder surgery: a prospective randomized controlled trial.” Journal of shoulder and elbow surgery 29.2 (2020): 212-216.