key: cord-0820986-mm0hdoxm
authors: Levy, Benjamin J.; Grimm, Nathan L.; Jimenez, Andrew E.; Shea, Kevin P.; Mazzocca, Augustus D.
title: Is There Value in the Routine Practice of Discarding the Incision Scalpel From the Surgical Field to Prevent Deep Wound Contamination with C. acnes?
date: 2020-08-06
journal: J Shoulder Elbow Surg
DOI: 10.1016/j.jse.2020.07.035
sha: ec7e0deaf78a76441393a22136b10153b212ed1b
doc_id: 820986
cord_uid: mm0hdoxm

Abstract Background Cutibacterium acnes (C. acnes) is found in skin flora of the shoulder and is the most common microbe identified in periprosthetic shoulder infections. The purpose of this study is to determine if there is C. acnes present on the incision scalpel in patients undergoing shoulder arthroplasty despite extensive skin preparation techniques to prevent wound contamination. Methods The authors collected a consecutive case series of patients meeting inclusion criteria. Patients were included if they underwent either primary or revision shoulder arthroplasty at the tertiary-care hospital with the senior author during the study period. Culture swab samples, testing for presence of C. acnes, were collected from 17 consecutive patients who underwent shoulder arthroplasty with a single, fellowship-trained surgeon between November 2019 and March 2020. Culture reports were recorded as “positive” or “negative” after 21 days. Institutional Review Board approval of the study protocol was obtained. The null hypothesis was that there would be no cases with knife blades “culture positive” for C. acnes. Results 17 patients were identified and fit inclusion criteria. There were 12 males (mean age 64.3y, range 48y-79y) and 5 females (mean age 69.8y, range 59y-79y). Two patients (11.8%) were found to have C. acnes growth on the skin knife. Both patients were males over the age of 70 undergoing primary reverse shoulder arthroplasty with no history of previous shoulder infections. Conclusion The presence of C. acnes on the skin blade in 2 patients validates concerns that there is C. acnes present in dermal tissue despite extensive attention to eradication of these microbes. There was a high rate of C. acnes contamination on scalpel blades used for initial skin incisions and the authors conclude that there is value in discarding these blades from the surgical field.

microbes. There was a high rate of C. acnes contamination on scalpel blades used for initial skin 23 incisions and the authors conclude that there is value in discarding these blades from the surgical 24 field. Infection following shoulder arthroplasty is a catastrophic outcome, occurring in 1-19% of 30 primary, and approximately 15% of reported revision cases. 13, 18, 24 Infection with Cutibacterium 31 acnes, better known as C. acnes (recently re-classified from its former identification as 32 Propionibacterium acnes, or P. acnes 4,17,23 ), represents a significant portion of these 33 infections. 6, 14, 18, 19, 26 C. acnes is a frequent culprit in patients with chronic periprosthetic 34 infections, in particular. 9, 13, 26 C. acnes is a gram-positive, anaerobic bacillus that is a common in patients with periprosthetic shoulder infections. 13 Though the skin is commonly noted to be 42 the area of concern for C. acnes infection, recent work has found the microbe to be cultured from deeper within surgical wounds as well. 26 The ubiquity of C. acnes throughout the soft tissues of 44 the shoulder, particularly in the skin and subcuticular layers has raised concern amongst shoulder 45 surgeons, especially when performing arthroplasty. Given rates and consequences of 46 periprosthetic infections, orthopedic surgeons have emphasized preoperative eradication of skin flora, notably C. acnes, from the dermal layers via skin prep and intravenous antibiotic usage.

Standard skin prep solutions (e.g. chlorhexidine gluconate, betadine soap) in addition to 49 solutions specifically targeted to eradicate C. acnes (e.g. hydrogen peroxide, benzoyl peroxide, 50 and intraoperative vancomycin powder) are commonly used, however no consensus exists 51 regarding a standardized protocol. 2, 3, 8, 11, 15, 20, 25 Despite these multifaceted approaches to 52 prevention, periprosthetic infections with C. acnes have persisted and remain a significant The authors propose this study as a pilot work to identify the potential presence of culture-56 identifiable C. acnes present on the scalpel blade used for initial skin incision despite exhaustive 57 skin prep protocols to eradicate them. Presence of the microbe on any skin blades raises the 58 concern for intraoperative contamination and subsequent infection, and the need for evaluation 59 of preoperative and perioperative practice to prevent infection. The authors hypothesize that 60 there will be evidence of C. acnes present in a small subset of patients' skin blade culture 61 samples. Patients were included in the analysis if they underwent either primary or revision shoulder 73 arthroplasty with the senior author during the study period. Patients undergoing any non-74 arthroplasty procedure were excluded from data collection. Patient demographic information was 75 gathered, as well as procedure details. (Table 1) 76 77

As is standard at the authors' institution, patients performed 4% chlorhexidine gluconate 

In total, 17 consecutive patients undergoing shoulder arthroplasty with the senior author were 117 identified and fit inclusion criteria for this study. No patients were excluded from analysis for 118 any reason. There were 12 males (mean age 64.3y, range 48y-79y) and 5 females (mean age 119 69.8y, range 59y-79y). 11 cases were for primary arthroplasty (10 reverse total shoulder 120 arthroplasty and 1 anatomic total shoulder arthroplasty), and 6 cases were for revision 121 arthroplasty (3 as part of two-stage revision procedures). Four patients had a history of previous 122 ipsilateral shoulder infection; and were undergoing revision surgery (two second stage revisions 123 of antibiotic spacer to reverse total shoulder arthroplasty, one first stage revision -explant of 124 total shoulder arthroplasty to antibiotic spacer, and one single stage revision from total shoulder 125 arthroplasty to reverse total shoulder arthroplasty). One of these four patients had prior history of Though it is often difficult to prove the source of infection, C. acnes has been identified as the 148 microorganism of interest in many patients with periprosthetic infections. 6,13 A recent study by 149 Torrens et al identified C. acnes in 18.8% of patients undergoing primary reverse total shoulder 150 arthroplasties, via intraoperative soft tissue culture. 26 The work of the current study underscores the widespread prevalence of C. acnes, present in greater than 10% of patients in the small 152 cohort, despite a thorough protocol to eradicate the microbe from the surgical field (extensive 153 preoperative and intraoperative skin scrub, including hydrogen peroxide). However, the authors 154 do caution that more work must be done to correlate the rate of skin blade contamination with 155 deep wound infections. The senior author employs a strategy of routinely discarding the knife used for skin incision 171 immediately after first incision. Though the current study does not have measurable outcomes 172 regarding the efficacy of this practice, we feel this strategy serves two purposes. First, as demonstrated by the positive skin blade results in this study, there is measurable C. acnes present 174 on the knife following incision, which could then contaminate the deep wound. Second, and 175 perhaps equally as important, the senior authors feel that discarding this knife "sets a tone" for 176 the entire operating room of increased attention to sterile technique. When the knife is discarded, 177 a message is conveyed to everyone present that extra attention is being paid to preventing 178 infection. Though this is difficult to quantify, the authors believe this is influential to preventing 179 subsequent infections. Previous works have examined the practice of discarding the "skin knife," 

Propionibacterium acnes: from 199 commensal to opportunistic biofilm-associated implant pathogen

Antibiotic Prophylaxis and Prevention of Surgical Site Infection 202 in Shoulder and Elbow Surgery

Hydrogen peroxide skin preparation reduces 205

Cutibacterium acnes in shoulder arthroplasty: a prospective, blinded, controlled trial

Cutibacterium 208 acnes (Propionibacterium acnes) and acne vulgaris: a brief look at the latest updates

The contaminated skin-knife

A surgical myth

Infection after primary anatomic versus primary 213 reverse total shoulder arthroplasty

Bactericidal efficacy of 216 hydrogen peroxide on Cutibacterium acnes

In vitro susceptibility of Propionibacterium 219 acnes to simulated intrawound vancomycin concentrations

Propionibacterium in Shoulder Arthroplasty: 222 What We Think We Know Today

Preoperative skin cultures are after periprosthetic shoulder infection: a systematic review

Outcomes in the treatment of periprosthetic joint 238 infection after shoulder arthroplasty: a systematic review

Survey of 241 shoulder arthroplasty surgeons' methods for infection avoidance of Propionibacterium

Propionibacterium acnes 244 colonization of the human shoulder

Recent advances in understanding Propionibacterium acnes

Cutibacterium acnes) in acne

Cutibacterium 249 acnes and the shoulder microbiome

Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder 253

Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during 256 shoulder surgery

Editorial Commentary: Already "Stealth" Organism Propionibacterium 259 acnes Goes Covert by Changing Its Name to Cutibacterium acnes: Shoulder Bacterial 260

Should we use a separate knife for the skin?

The natural history of cutaneous propionibacteria, and 264 reclassification of selected species within the genus Propionibacterium to the proposed 265 novel genera Acidipropionibacterium gen

Analysis of 4063 complications of 269 shoulder arthroplasty reported to the US Food and Drug Administration from 2012 to 270 2016

Addition of 3% hydrogen peroxide to 272 standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder 273 surgery: a prospective randomized controlled trial

Cutibacterium acnes in primary 276 reverse shoulder arthroplasty: from skin to deep layers