Related Experiment Video
Updated: Jul 19, 2025
Author Spotlight: Treating Frozen Shoulder with Small Needle Knife Therapy
Published on: November 17, 2023
Efficacy of antimicrobial washes before shoulder surgery against Cutibacterium: a systematic review and meta-analysis
Andrew P Collins1, Jeffrey Simpson1, Bradley Richey1
1Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA.
Background:
Cutibacterium acnes is a commensal intradermal microorganism that is commonly isolated at revision shoulder arthroplasty. Standard practice chlorhexidine gluconate (CHG) skin preparation agents have limited effectiveness at eradicating C. acnes in the dermis. Benzoyl peroxide (BPO) has demonstrated effectiveness against C. acnes. This meta-analysis compares the efficacy of at-home shoulder decolonization before surgery using CHG vs. BPO to reduce shoulder C. acnes burden.
Methods:
This was a Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review. PubMed and MEDLINE databases were searched for studies evaluating the effects of CHG and BPO in reducing C. acnes at the shoulder. Trial results were extracted and pooled using a random effects model, separating data from randomized controlled trials (RCTs) and non-RCTs. Methodologic quality of studies was assessed using the Cochrane Risk of Bias Assessment Tools.
Results:
Ten studies (589 patients) were included. RCTs showed that both BPO and CHG led to significant reductions in culture positivity compared with negative controls (risk ratio [RR] with 95% confidence interval [CI] = 0.20 [0.13, 0.30], P < .0001 and 0.46 [0.37, 0.57], P < .0001, respectively). Non-RCT data demonstrated similar results comparing BPO and CHG to the control (RR with 95% CI = 0.34 [0.21, 0.57], P < .0001 and 0.31 [0.20, 0.49], P < .0001, respectively). Comparing BPO and CHG, RCT data showed a significant reduction in culture positivity with BPO (RR with 95% CI = 0.46 [0.27, 0.77], P < .009). Of RCTs, 5 were low and one was of moderate risk of bias. Of non-RCTs, 3 had low risk of bias, whereas one had moderate risk of bias.
Conclusion:
This review demonstrated that preoperative CHG and BPO can reduce C. acnes at the shoulder. However, BPO exhibits greater efficacy than CHG, potentially because of the compound's ability to penetrate the dermis. BPO is a simple and economical agent that may reduce joint exposure to C. acnes in shoulder surgery.
Insights
Benzoyl peroxide (BPO) is more effective than chlorhexidine gluconate (CHG) at reducing Cutibacterium acnes before shoulder surgery. BPO offers a simple, economical option to decrease bacterial burden and improve surgical outcomes.
Area of Science:
- Orthopedics
- Infectious Disease
- Dermatology
Background:
- Cutibacterium acnes (C. acnes) is common in revision shoulder arthroplasty.
- Standard chlorhexidine gluconate (CHG) has limited effectiveness against dermal C. acnes.
- Benzoyl peroxide (BPO) shows promise for C. acnes eradication.
Purpose of the Study:
- Compare the efficacy of at-home shoulder decolonization using CHG versus BPO.
- Evaluate the reduction of C. acnes burden prior to shoulder surgery.
Main Methods:
- Systematic review and meta-analysis following PRISMA guidelines.
- Searched PubMed and MEDLINE for studies on CHG and BPO for shoulder C. acnes.
- Pooled data from randomized controlled trials (RCTs) and non-RCTs using random effects models.
Main Results:
- Both BPO and CHG significantly reduced C. acnes culture positivity compared to controls in RCTs and non-RCTs.
- BPO demonstrated a statistically significant greater reduction in C. acnes culture positivity compared to CHG in RCTs.
- Methodologic quality assessment revealed most studies had low to moderate risk of bias.
Conclusions:
- Preoperative CHG and BPO effectively reduce shoulder C. acnes.
- BPO appears more efficacious than CHG, potentially due to better dermal penetration.
- BPO presents a simple, cost-effective agent for reducing C. acnes in shoulder surgery patients.
Related Concept Videos
01:23Hand hygiene
Hand washing...
01:28Antimicrobial Effectiveness
01:18Surface Membrane Barriers
The outer layer of the skin, the epidermis, is a robust barrier comprising layers of closely packed keratinized cells. This dense arrangement prevents microbes from penetrating the body. The periodic shedding of epidermal cells...
01:19Handwashing II: Pre-procedure and Initial Procedure Steps
The hand washing procedure itself includes the following steps. First, cover cuts, if any, on hands with a waterproof dressing. Cuts and abrasions can become contaminated with bacteria hindering the ability to clean the area thoroughly. In addition, repeated hand washing can worsen an injury. The nails must be short and clean, without nail...
01:15Handwashing III: During the Procedure and Post-Procedure Steps