Efficacy of Home Prophylactic Benzoyl Peroxide and Chlorhexidine in Shoulder Surgery: A Systematic Review and Meta-Analysis.

Two predominant prophylactic home skin-disinfection regimens exist in shoulder surgery, benzoyl peroxide and chlorhexidine. Of these 2 regimens, benzoyl peroxide gel is more effective than chlorhexidine in reducing the rate of positive Cutibacterium cultures on the skin surface. At present, there are no studies that assess the impact of these home prophylactic measures on clinical infection rates.

Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients.

INTRODUCTION: Home chlorhexidine washes prior to shoulder surgery are commonly used in an attempt to reduce the skin bacterial load. However, recent studies have suggested that this agent is relatively ineffective against Cutibacterium acne. Benzoyl peroxide soap is a treatment for acne, but evidence regarding its effectiveness as prophylaxis in shoulder surgery is lacking. Therefore, the objective of this study was to compare the effectiveness of home chlorhexidine washes with benzoyl peroxide soap (BPO) in patients undergoing shoulder arthroplasty surgery in reducing Cutibacterium levels on the skin surface and in the dermis. METHODS: Fifty male patients planning to undergo shoulder arthroplasty were consented to be randomized into treatment with 4% chlorhexidine solution (CHG) and 10% benzoyl peroxide soap (BPO) used to wash the operative shoulder the night prior and morning of surgery. Skin swabs prior to incision and dermal wound swabs after incision were obtained, and the bacterial load was reported in a semiquantitative manner as the Specimen Cutibacterium Value (SpCuV). The two groups were compared with regards to the percent positivity of the skin surface and incised dermal edge as well as the bacterial load at each site. RESULTS: Skin surface swabs were positive in 100% of patients using CHG and 100% of patients using BPO soap. The Cutibacterium load (SpCuV) on the skin surface was similar between the two groups (CHG 1.6 ± 1.1 vs. BPO 1.5 ± 1.4, p = 0.681). The percentages of dermal cultures that were positive were not significantly different between the two groups (CHG 61% vs BPO 46%, p = 0.369). The Cutibacterium load (SpCuV) on the incised dermal edge was similar between the two groups (CHG 0.8 ± 1.0 vs. BPO 0.8 ± 1.4, p = 0.991). DISCUSSION: Neither BPO soap nor chlorhexidine washes prior to shoulder surgery were effective in eliminating Cutibacterium from the skin surface or the incised dermal edge. Further study of means of reducing the Cutibacterium load of the skin at the time of shoulder arthroplasty is warranted.

The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision Shoulder Arthroplasty.

BACKGROUND: When performing revision shoulder arthroplasty, surgeons do not have access to the results of intraoperative culture specimens and will administer empiric antibiotics to cover for the possibility of deep infection until the culture results are finalized. The purpose of this study was to report the factors associated with the initiation, modification, and adverse events of 2 different postoperative antibiotic protocols in a series of revision shoulder arthroplasties. METHODS: In this study, 175 patients undergoing revision shoulder arthroplasty were treated with either a protocol of intravenous (IV) antibiotics if there was a high index of suspicion for infection or a protocol of oral antibiotics if the index of suspicion was low. Antibiotics were withdrawn if cultures were negative and were modified as indicated if the cultures were positive. Antibiotic course, modification, and adverse effects to antibiotic administration were documented. RESULTS: On univariate analysis, factors significantly associated with the initiation of IV antibiotics were male sex (p < 0.001), history of infection (p < 0.001), intraoperative humeral loosening (p = 0.003), and membrane formation (p < 0.001). On multivariate analysis, male sex (p = 0.003), history of infection (p = 0.003), and membrane formation (p < 0.001) were found to be independent predictors of the initiation of IV antibiotics. On the basis of preoperative and intraoperative characteristics, surgeons anticipated the culture results in 75% of cases, and modification of antibiotic therapy was required in 25%. The modification from oral to IV antibiotics due to positive culture results was made significantly more often in male patients (p < 0.001). Adverse effects of antibiotic administration occurred in 19% of patients. The rates of complications were significantly lower in the patients treated with oral antibiotics and a shorter course of antibiotics (p < 0.001). CONCLUSIONS: Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. Further study is needed to balance the effectiveness and risks of post-revision antibiotic treatment given the frequency of antibiotic-related complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.