The management of the shoulder skin microbiome (Cutibacterium acnes) in the context of shoulder surgery: a review of the current literature

Background This review aims to establish current knowledge of the shoulder skin microbiome and how to manage the bacteria that reside within it. Methods A review was undertaken of the current literature through OvidSP. All abstracts were reviewed by three independent researchers. Results Thirty-five studies met the inclusion criteria. With forward referencing an additional 14 were included. None commented on organisms specific to the shoulder microbiome other than Cutibacterium acnes. Therefore, this review is focussed on the current knowledge of C. acnes. Discussion C. acnes is a skin commensal within the pilo-sebaceous glands reported to be the primary pathogen in up to 86% of shoulder joint infections. Pre-operative culture of unprepared skin can be indicative of underlying joint infection in shoulder arthroplasty revision. Intra-articular biopsies may have a high false positive due to skin contamination. Correlating the number of positive samples and certain associated signs can give a greater than 90% probability of a true infection. Standard surgical skin preparation, peri-surgical intravenous antibiotics and oral pre-operative antibiotics do not reduce bacterial load within the skin. However, topical benzoyl peroxide and clindamycin have both demonstrated significantly reduced bacteria load. Phylogenetically there are six main types. Patients may have more than one phenotype present during infection.

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Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder region

10.21203/rs.2.17411/v1 ◽

2019 ◽

Author(s):

Dorothea Dörfel ◽

Georg Daeschlein ◽

Matthias Maiwald ◽

Gerald Müller ◽

Robert Hudek ◽

...

Keyword(s):

Povidone Iodine ◽

Surgical Site Infections ◽

Shoulder Surgery ◽

Skin Microbiome ◽

Negative Effects ◽

Skin Preparation ◽

Prolonged Contact ◽

Skin Flora ◽

Cutibacterium Acnes ◽

Skin Antisepsis

Abstract Background: Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an important agent of surgical site infections (SSI), particularly in shoulder surgery, and is difficult to target with skin antisepsis. We hypothesized that prolonged preparation with an agent that penetrates deeper into the skin is more effective in shoulder surgery. Thus, we compared two different classes of antiseptics, each combined with alcohol, and each applied with two different contact times. Methods: Shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC; 2% w/v CHG, 55% w/v [70% v/v] 2-propanol) or alcohol-based povidone iodine (PVP-I-ALC; 3.24% w/v PVP-I, 38.9% w/v 2-propanol, 37.3% w/v ethanol). Skin sites were sampled before, immediately after, and 3 h after treatment. Results: Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min and immediate sampling, but not after prolonged contact times and 3-h sampling. Anaerobic flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after standard and prolonged contact times and immediate sampling, but not after 3-h sampling. None of the volunteers reported negative effects from skin antisepsis. Conclusions: PVP-I-ALC is more efficacious than CHG-ALC for topical skin antisepsis regarding the anaerobic flora on the skin of the shoulder. Standard and prolonged contact times demonstrated superiority for PVP-I-ALC for samples taken immediately, but missed significance 3 h after application. The clinical relevance of these findings should be studied with SSI as an endpoint.

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Bacteriophage therapy for bone and joint infections

The Bone & Joint Journal ◽

10.1302/0301-620x.103b2.bjj-2020-0452.r2 ◽

2021 ◽

Vol 103-B (2) ◽

pp. 234-244

Author(s):

Bryan P. Gibb ◽

Michael Hadjiargyrou

Keyword(s):

Bacterial Infections ◽

Current Knowledge ◽

Joint Infection ◽

Bacteriophage Therapy ◽

Antibiotic Resistant ◽

Joint Infections ◽

Bone And Joint Infections ◽

Orthopaedic Infections

Antibiotic resistance represents a threat to human health. It has been suggested that by 2050, antibiotic-resistant infections could cause ten million deaths each year. In orthopaedics, many patients undergoing surgery suffer from complications resulting from implant-associated infection. In these circumstances secondary surgery is usually required and chronic and/or relapsing disease may ensue. The development of effective treatments for antibiotic-resistant infections is needed. Recent evidence shows that bacteriophage (phages; viruses that infect bacteria) therapy may represent a viable and successful solution. In this review, a brief description of bone and joint infection and the nature of bacteriophages is presented, as well as a summary of our current knowledge on the use of bacteriophages in the treatment of bacterial infections. We present contemporary published in vitro and in vivo data as well as data from clinical trials, as they relate to bone and joint infections. We discuss the potential use of bacteriophage therapy in orthopaedic infections. This area of research is beginning to reveal successful results, but mostly in nonorthopaedic fields. We believe that bacteriophage therapy has potential therapeutic value for implant-associated infections in orthopaedics. Cite this article: Bone Joint J 2021;103-B(2):234–244.

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Staphylococcus epidermidis: A Potential New Player in the Physiopathology of Acne?

Dermatology ◽

10.1159/000499858 ◽

2019 ◽

Vol 235 (4) ◽

pp. 287-294 ◽

Cited By ~ 13

Author(s):

Jean-Paul Claudel ◽

Nicole Auffret ◽

Marie-Thérèse Leccia ◽

Florence Poli ◽

Stéphane Corvec ◽

...

Keyword(s):

Human Skin ◽

Staphylococcus Epidermidis ◽

Skin Disease ◽

Potential Role ◽

Current Knowledge ◽

Treatment Options ◽

Skin Microbiome ◽

Cutibacterium Acnes ◽

Skin Commensals

Background: Cutibacterium acnes has been identified as one of the main triggers of acne. However, increasing knowledge of the human skin microbiome raises questions about the role of other skin commensals, such as Staphylococcus epidermidis, in the physiopathology of this skin disease. Summary: This review provides an overview of current knowledge of the potential role of S. epidermidis in the physiopathology of acne. Recent research indicates that acne might be the result of an unbalanced equilibrium between C. acnes and S. epidermidis,according to dedicated interactions. Current treatments act on C. acnesonly. Other treatment options may be considered, such as probiotics derived from S. epidermidis to restore the naturally balanced microbiota or through targeting the regulation of the host’s AMP mediators. Key Messages: Research seems to confirm the beneficial role of S. epidermidis in acne by limiting C. acnes over-colonisation and inflammation.

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Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-020-00874-8 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Dorothea Dörfel ◽

Matthias Maiwald ◽

Georg Daeschlein ◽

Gerald Müller ◽

Robert Hudek ◽

...

Keyword(s):

Povidone Iodine ◽

Surgical Site Infections ◽

Reduction Factor ◽

Skin Microbiome ◽

Coagulase Negative Staphylococci ◽

Skin Preparation ◽

Prolonged Contact ◽

Skin Flora ◽

Cutibacterium Acnes ◽

Shoulder Region

Abstract Background Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times. Methods Using a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. Results Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported. Conclusions PVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.

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Povidone-iodine-alcohol is superior to chlorhexidine-alcohol in its antimicrobial efficacy on the anaerobic microbial flora in surgical skin preparation of the shoulder Region

10.21203/rs.3.rs-37611/v1 ◽

2020 ◽

Author(s):

Dorothea Dörfel ◽

Georg Daeschlein ◽

Matthias Maiwald ◽

Gerald Müller ◽

Robert Hudek ◽

...

Keyword(s):

Povidone Iodine ◽

Shoulder Surgery ◽

Skin Microbiome ◽

Coagulase Negative Staphylococci ◽

Skin Preparation ◽

Prolonged Contact ◽

Skin Flora ◽

Significant Difference ◽

Cutibacterium Acnes ◽

Skin Antisepsis

Abstract Background Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery and is difficult to target with skin antisepsis. We hypothesized that prolonged preparation with an agent that penetrates more deeply into the skin is more effective in shoulder surgery. Thus, we compared two different classes of antiseptics, each combined with alcohol, and each applied with two different contact times. Methods Using a cross-over study design, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC; 2% w/v CHG, 55% w/v [70% v/v] 2-propanol) or alcohol-based povidone-iodine (PVP-I-ALC; 3.24% w/v PVP-I, 38.9% w/v 2-propanol, 37.3% w/v ethanol). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. Results Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55±0.75 vs. 1.94±0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 3 of 16 and 1 of 16 samples after 2.5-min and 30-min CHG-ALC application and immediate sampling, respectively. Anaerobic flora, mostly consisting of C. acnes, was reduced more effectively by PVP-I-ALC than by CHG-ALC after standard (RF 3.96±1.46 vs. 1.74±1.24, p < 0.01) and prolonged (RF 3.14±1.20 vs. 1.38±1.16, p < 0.01) contact times. Sampling 3 h after treatment did not show any significant difference. None of the volunteers reported adverse events. Conclusions PVP-I-ALC is more efficacious than CHG-ALC for topical skin antisepsis concerning the anaerobic flora on the skin of the shoulder. Standard and prolonged contact times demonstrated superiority for PVP-I-ALC for samples taken immediately, but missed significance 3 h after application. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery and the need to prevent infections caused by these organisms. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.

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Plasma Cell Infiltration on Histopathological Samples of Chronic Bone and Joint Infections due to Cutibacterium acnes: A series of 21 Cases

Journal of Bone and Joint Infection ◽

10.7150/jbji.46187 ◽

2020 ◽

Vol 5 (4) ◽

pp. 205-211

Author(s):

Alexis Trecourt ◽

Marie Brevet ◽

Anne Champagnac ◽

Anne Conrad ◽

Jérôme Josse ◽

...

Keyword(s):

Plasma Cell ◽

Plasma Cells ◽

Joint Infection ◽

High Plasma ◽

Cell Infiltration ◽

Histopathological Analysis ◽

Histopathological Diagnosis ◽

Joint Infections ◽

Plasma Cell Infiltration ◽

Cutibacterium Acnes

Abstract. Introduction: Histopathological definition of bone and joint infection (BJI) is based on Mirra's criterion (≥ 5 polymorphonuclears (PMNs) per field in 5 high power fields (HPFs)). However, this definition does not seem appropriate for chronic BJIs caused by slow-growing germs such as Cutibacterium acnes (C. acnes). The aim of this study was to confirm that Mirra's criterion is not adequate for diagnosis of BJIs due to C. acnes. The second objective was to determine if plasma cell infiltration could be useful for the diagnosis of chronic BJIs due to C. acnes.Methods: We retrospectively selected 25 consecutive patients from 2009 to 2013 with chronic BJIs due to C. acnes. Histological analysis was performed on the 21 cases with at least two C. acnes positive cultures. In addition of Mirra's criterion, the number of plasma cells (≥5 plasma cells/5 HPFs, defined as “CRIOAc Lyon's criterion”) was implemented in the histopathological analysis. Patients were defined as infected, if at least one of the two criteria were present.Results: According to Mirra's and CRIOAc Lyon's criteria, positive histopathology was observed in 12 (57.1%) and 15 (71.4%) cases respectively. Considering the 9 cases with negative Mirra's criterion, high plasma cell infiltration (≥5 plasma cells per field/5 HPFs) was observed in 5 cases (55.6%), and low plasma cells infiltration (2-5 plasma cells per field/5 HPFs) was observed in 4 other cases (44.4%).Conclusions: Adding CRIOAc Lyon's criterion to Mirra's criterion might restore some histopathological diagnosis of chronic BJIs due to C. acnes when a chronic BJI is clinically suspected.

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Prevention of Prosthetic Joint Infection: From Traditional Approaches towards Quality Improvement and Data Mining

Journal of Clinical Medicine ◽

10.3390/jcm9072190 ◽

2020 ◽

Vol 9 (7) ◽

pp. 2190 ◽

Cited By ~ 2

Author(s):

Jiri Gallo ◽

Eva Nieslanikova

Keyword(s):

Data Mining ◽

Immune Response ◽

Quality Improvement ◽

Joint Infection ◽

Bacterial Load ◽

Joint Infections ◽

Prosthetic Joint ◽

Increased Risk ◽

Prosthetic Joint Infections ◽

Preventative Strategy

A projected increased use of total joint arthroplasties will naturally result in a related increase in the number of prosthetic joint infections (PJIs). Suppression of the local peri-implant immune response counters efforts to eradicate bacteria, allowing the formation of biofilms and compromising preventive measures taken in the operating room. For these reasons, the prevention of PJI should focus concurrently on the following targets: (i) identifying at-risk patients; (ii) reducing “bacterial load” perioperatively; (iii) creating an antibacterial/antibiofilm environment at the site of surgery; and (iv) stimulating the local immune response. Despite considerable recent progress made in experimental and clinical research, a large discrepancy persists between proposed and clinically implemented preventative strategies. The ultimate anti-infective strategy lies in an optimal combination of all preventative approaches into a single “clinical pack”, applied rigorously in all settings involving prosthetic joint implantation. In addition, “anti-infective” implants might be a choice in patients who have an increased risk for PJI. However, further progress in the prevention of PJI is not imaginable without a close commitment to using quality improvement tools in combination with continual data mining, reflecting the efficacy of the preventative strategy in a particular clinical setting.

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Perioperative Antibiotic Prophylaxis Has No Effect on Time to Positivity and Proportion of Positive Samples: a Cohort Study of 64Cutibacterium acnesBone and Joint Infections

Journal of Clinical Microbiology ◽

10.1128/jcm.01576-17 ◽

2017 ◽

Vol 56 (2) ◽

Cited By ~ 2

Author(s):

Alexia Anagnostopoulos ◽

Daniel A. Bossard ◽

Bruno Ledergerber ◽

Patrick O. Zingg ◽

Annelies S. Zinkernagel ◽

...

Keyword(s):

Antibiotic Prophylaxis ◽

Joint Infection ◽

Surgical Site Infections ◽

Content Type ◽

Perioperative Antibiotic Prophylaxis ◽

Perioperative Prophylaxis ◽

Joint Infections ◽

Time To Positivity ◽

Cutibacterium Acnes ◽

Perioperative Antibiotics

ABSTRACTIf a bone or joint infection is suspected, perioperative antibiotic prophylaxis is frequently withheld until intraoperative microbiological sampling has been performed. This practice builds upon the hypothesis that perioperative antibiotics could render culture results negative and thus impede tailored antibiotic treatment of infections. We aimed to assess the influence of antibiotic prophylaxis within 30 to 60 min before surgery on time to positivity of microbiological samples and on proportion of positive samples inCutibacterium acnesbone and joint infections. Patients with at least one sample positive forC. acnesbetween January 2005 and December 2015 were included and classified as having an “infection” if at least 2 samples were positive; otherwise they were considered to have a sample “contamination.” Kaplan-Meier curves were used to illustrate time to culture positivity. We found 64 cases with aC. acnesinfection and 46 classified as having aC. acnescontamination. Application of perioperative prophylaxis significantly differed between the infection and contamination groups (72.8% versus 55.8%;P< 0.001). Within the infection group, we found no difference in time to positivity between those who had or had not received a perioperative prophylaxis (7.07 days; 95% confidence interval [CI], 6.4 to 7.7, versus 7.11 days; 95% CI, 6.8 to 7.5;P= 0.3). Also, there was no association between the proportion of sample positivity and the application of perioperative prophylaxis (71.6% versus 65.9%;P= 0.39). Since perioperative prophylaxis did not negatively influence the microbiological yield inC. acnesinfections, antibiotic prophylaxis can be routinely given to avoid surgical site infections.

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Skin microbiome modulation induced by probiotic solutions

10.1101/423285 ◽

2018 ◽

Author(s):

Bernhard Paetzold ◽

Jesse R. Willis ◽

Joao Lima ◽

Nastassia Knodlseder ◽

Sven R. Quist ◽

...

Keyword(s):

Therapeutic Strategy ◽

Therapeutic Option ◽

Bacterial Load ◽

Skin Microbiome ◽

Fecal Transplant ◽

Microbiome Composition ◽

Disease States ◽

Cutibacterium Acnes ◽

Number Of Microorganisms ◽

Subtype H1

BackgroundThe skin is colonized by a large number of microorganisms, of which most are beneficial or harmless. However, disease states of skin have specific microbiome compositions that are different from those of healthy skin. Gut microbiome modulation through fecal transplant has proven as a valid therapeutic strategy in diseases such as Clostridium difficile infections. Therefore, techniques to modulate the skin microbiome composition may become an interesting therapeutic option in diseases affecting the skin such as psoriasis or acnes vulgaris.Here we have used mixtures of different skin microbiome components to alter the composition of a recipient skin microbiome.ResultsWe show that after sequential applications of a donor microbiome, the recipient microbiome becomes similar to that of the donor. After intervention, an initial, week-long phase is characterized by dominance of donor strains. The level of engraftment depends on the composition of the recipient and donor microbiomes, and the applied bacterial load. We observed higher engraftment using a multi-strain donor solution with recipient skin rich in Cutibacterium acnes subtype H1 and Leifsonia.ConclusionsWe have demonstrated the use of living bacteria to modulate skin microbiome composition.

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Genomic Analysis of Cutibacterium acnes Strains Isolated from Prosthetic Joint Infections

Microorganisms ◽

10.3390/microorganisms9071500 ◽

2021 ◽

Vol 9 (7) ◽

pp. 1500

Author(s):

Llanos Salar-Vidal ◽

Yvonne Achermann ◽

John-Jairo Aguilera-Correa ◽

Anja Poehlein ◽

Jaime Esteban ◽

...

Keyword(s):

Normal Skin ◽

Genomic Analysis ◽

Healthy Skin ◽

Common Cause ◽

Good Outcome ◽

Joint Infections ◽

Prosthetic Joint ◽

Prosthetic Joint Infections ◽

Cutibacterium Acnes ◽

Clinical Conditions

Cutibacterium acnes is a common cause of prosthetic joint infections (PJIs). The C. acnes population can be divided into six main phylotypes (IA1, IA2, IB, IC, II and III) that are associated with different clinical conditions and normal skin. A single-locus sequence typing (SLST) scheme can distinguish ten main SLST types: A-E (all IA1), F (IA2), G (IC), H (IB), K (II), L (III). We genome-sequenced and compared 16 strains of C. acnes isolated from healthy skin (n = 4) and PJIs (n = 12), including six PJI cases with a good outcome (four shoulder PJIs, one hip PJI, one knee PJI) and six with infection relapse (three shoulder PJIs, three hip PJIs). The sequenced strains belonged to four different phylotypes (IA1, IA2, IB and II) and seven different SLST types. All five type IB strains (all SLST type H1) were PJI isolates (three hip PJIs, two shoulder PJIs), and four of these caused infection relapse (three hip PJIs, one shoulder PJI). Isolates from PJI cases with a good outcome belonged to three different phylotypes (IA, IB, II). Interestingly, four strains (three strains from PJI cases with good outcome and one strain from healthy skin) contained a linear plasmid; these strains belonged to different SLST types (A1, C1, F4, H1) and were isolated in three different hospitals. This study suggests that type IB strains have the potential to cause infection relapse, in particular regarding hip PJIs. Moreover, our study revealed that strains belonging to the same SLST type can differ in their accessory genome in different geographic locations, indicative of microevolution.

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