Cutibacterium acnes Why I Care,What I Do is this the culprit?

1. CutibacteriumacnesWhy I Care,What I Dois this the culprit? Mark H. Getelman, M.D. Co-Director Sports Medicine Fellowship Van Nuys, CA

2. Disclosures • I have something to disclose • Available at the AAOS website • Ortho Summit Program

3. Cutibacterium Acnes • Formerly called Proprionobacterium acnes • A known skin commensal • Anaerobic gram-positive bacillus (rod)

4. Cutibacterium Acnes • Found in skin-sebaceous glands of hair follicles • Colonized in dermis about the head and shoulder

5. Cutibacterium Acnes • May be present despite pre-op ABX prophylaxis and surgical skin prep • Tissue Inoculation rate can be nearly 20%! • ABX Prophylaxis reduces overall infection rate • 1.54  0.28%...but not C. acnes rate • May play a significant role in the etiology of OA

6. C. Acnes an opportunistic pathogen • Surgically induced bacterial seeding • May cause implant associated infection • Arthroplasty---reports up to 10%, 15% in Revision TSA • Arthroscopic RCR 2%

7. C. Acnes Risk factors • Males • Prolonged surgical time • Age <65 • Prior surgery • More hair > greater risk

8. Benefit of Surgical Shaving • Greater Bacterial Burden in clipped vs unclipped specimens PRIOR to skin prep • Conclusion: Removal of Axillary Hair no effect • No longer routinely performed

9. C. acnes • Difficult to diagnose • HIGH INDEX OF SUSPICION! • Pain is OFTEN only clinical sign • Usually Afebrile • WBC may be WNL • ESR and CRP may also be WNL as well • Need intra-operative Cultures

10. C. Acnes diagnosis • Improved diagnostic options • Prolonged HOLD CX for AT LEAST 14 Days! • Request both agar plate and broth specimens

11. Can We reduce the risk • Skin Prep? • Peri-operative Antibiotics? • Lots of Level V opinion • NO CONSENSUS!

12. CDC guidelines • Patients should shower/bathe night before surgery • Soap (antimicrobial or nonantimicrobial) or antiseptic agent • Antimicrobial prophylaxis—based on CPG • Topical antimicrobial agents should not be applied

13. 80 patients-arthroscopy and arthroplasty randomized 2 groups: • 118 mL 5% BPO gel (costs less than $10 per patient) • 4% CHG skin cleanser • Both groups applied to shoulder/axilla for 3 consecutive days • At surgery Cx from 4 sites about the op and non op shoulder prior to prepping/draping • No change observed for CHG treated compared to c/l side • Statistically sig reduction with BPO compared with CHG • Clinically NO patients experienced wound complications or clinical signs of infection, or unexplained pain

14. Hydrogen Vs. BenzoylPeroxide • Both are bleaching agents • Same mechanism of action • Break down cell wall • Release Oxygen and kill anaerobic bacteria • Exfoliant • Hydrogen Peroxide • Antimicrobial agent • Not recommended for open wounds

15. Hydrogen Vs. BenzoylPeroxide • Hydrogen Peroxide • Liquid form • Antimicrobial agent • Not recommended for open wounds • Benzoyl Peroxide • Viscous gel • Easier application

16. J Shoulder Elbow Surg. 2017 Jul;26(7):1190-1195. doi: 10.1016/j.jse.2017.03.003. Epub 2017 May 4. • Background: • “Dermatology literature demonstrates reduction of P. acnes colonization with benzoyl peroxide 5% and clindamycin phosphate 1.2% (BPO/C) topical gel • Powerful topical agent, allows penetration to deep dermal layer, • inhibitis development of abx resistance • BPO is bacteriocidal • single application of 10% bpo preop skin prep wash was ineffective reducing bacterial load • Superficial skin colonization: 72.5% primary, 76.7% revisions • Deep tissue inoculation during shoulder arthroscopy 19.6% after standard prep/prophabx • Methods: • 65 pts • Swabbed portal sites at preop visit and BPO/C was then applied at that time and instructed to apply nightly • Randomized into 2 groups: 1 preop application, or >1 (1-10) with ave. being 2.3 • 2nd culture obtained in OR just before chlorhexidine prep • Standard skin prep with chlorhexidine scrub, followed by chlorhexidine/alcohol paint • 3rd culture obtained from operative site under direct arthroscopic visualization through a cannula • Cultures held for 21 days

17. J Shoulder Elbow Surg. 2017 Jul;26(7):1190-1195. doi: 10.1016/j.jse.2017.03.003. Epub 2017 May 4. • Results: • Preop colonization: 47.7% (M: 80.6%, F:19.4%) • Topical gel was effective in eliminating 74.2% of skin colonization by day of surgery • >1 application: 78.9% • 1 application: 66.7% • Deep tissue cx: • >1 application group: 0% • No clinical infections detected @ f/u • 2 pts with + deep cx treated with 3 weeks doxycycline 100 mg • 1 case mild dermatitis skin reaction

18. What about Antibiotic Prophylaxis?

19. 10 patients • Each had double skin prep (Chloroprep) • Each given IV Ceftriaxone and Vancomycin • Ceftriaxone more effective against p. acnes than cefazolin with less side effects vs clindamycin • Vancomycin- additional coverage against p. acnes and coag-neg Staph • 5 tissue cultures obtained from each patient after antibiotic given • 2 shoulders had growth from 3/5 specimens • 1 had growth from 1 specimen • All + cx occurred within 17 days of incubation on anaerobic media • Conclusion: Propionibacterium can be recovered from primary arthroplasty wounds despite aggressive prophylaxis

20. LATEST PEER REVIEWED RECOMMENDATIONS JSES, JULY 2018

21. JSES, JULY 2018

22. JSES, JULY 2018 Considerations:

23. WHAT I DO…Level V? • Routine • Cefazolin routinely • Clinda/Vanco for PCN allergy • CHG/Alcohol Prep Stick • Change Gloves after draping • Higher Risk Patients: • MALE TEEN or Open Shoulder Case with Implant • Triple Prep: CHG SCRUB -> Hydrogen Peroxide Rinse->CHG/Alcohol Prep Stick • Consider Topical Clinda/BPO Pre-op and Oral Doxy Post-op

24. Thank You Thank You