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Management of Propionibacterium acnes infection after shoulder surgery

  • Shoulder Surgery: Complications (X Li, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Propionibacterium acnes (P. acnes) is a gram-positive anaerobic bacillus commonly isolated from the flora of the face, chest, and axilla region. It has emerged as a major pathogen responsible for postoperative shoulder infections after both arthroscopy and arthroplasty procedures. Patients with P. acnes shoulder infection typically present with normal laboratory values (white blood cells (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)) making diagnosis difficult. Several intraoperative tissue cultures should be obtained and cultured in both agar plate and broth in aerobic and anaerobic conditions for a minimum of 13 days to optimize the sensitivity and specificity to detect P. acnes. The utilization of intraoperative frozen sections to detect P. acnes infection is not reliable. Risk factors include male, cloudy synovial fluid, lucencies around the implant, and periprosthetic membrane formation. Managements include irrigation and debridement, single or two-staged revision, and intravenous antibiotics. Open biopsy prior to the final implantation (two-staged revision) may help detect persistent P. acnes infection. Penicillin and cephalosporins are effective against clinical P. acnes infection and biofilm in vitro. Combination antibiotic therapy with rifampin and daptomycin may further increase the clinical efficacy of treatment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Department of Research & Scientific Affairs, American Academy of Orthopaedic Surgeon. <br />Annual incidence of common musculoskeletal procedures and treatment. American Academy of Orthopaedic Surgeons. 2014(March).

  2. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the united states. J Bone Joint Surg Am. 2011;93(24):2249–54. doi:10.2106/JBJS.J.01994.

    Article  PubMed  Google Scholar 

  3. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Should Elbow Surg. 2010;19(8):1115–20. doi:10.1016/j.jse.2010.02.009.

    Article  Google Scholar 

  4. Athwal GS, Sperling JW, Rispoli DM, Cofield RH. Deep infection after rotator cuff repair. J Should Elbow Surg. 2007;16(3):306–11.

    Article  Google Scholar 

  5. Topolski MS, Chin PY, Sperling JW, Cofield RH. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Should Elbow Surg. 2006;15(4):402–6.

    Article  Google Scholar 

  6. Patel A, Calfee RP, Plante M, Fischer SA, Green A. Propionibacterium acnes colonization of the human shoulder. J Should Elbow Surg. 2009;18(6):897–902. doi:10.1016/j.jse.2009.01.023.

    Article  Google Scholar 

  7. Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009;91(8):1949–53. doi:10.2106/JBJS.H.00768.

    Article  PubMed  Google Scholar 

  8. DOUGLAS HC, GUNTER SE. The taxonomic position of Corynebacterium acnes. J Bacteriol. 1946;52:15–23.

    PubMed Central  Google Scholar 

  9. Grice EA, Segre JA. The skin microbiome. Nat Rev Microbiol. 2011;9(4):244–53. doi:10.1038/nrmicro2537.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  10. Csukas Z, Banizs B, Rozgonyi F. Studies on the cytotoxic effects of Propionibacterium acnes strains isolated from cornea. Microb Pathog. 2004;36(3):171–4.

    Article  PubMed  Google Scholar 

  11. Webster GF, Leyden JJ, Musson RA, Douglas SD. Susceptibility of Propionibacterium acnes to killing and degradation by human neutrophils and monocytes in vitro. Infect Immun. 1985;49(1):116–21.

    PubMed Central  CAS  PubMed  Google Scholar 

  12. Bruggemann H. Insights in the pathogenic potential of Propionibacterium acnes from its complete genome. Semin Cutan Med Surg. 2005;24(2):67–72.

    Article  PubMed  Google Scholar 

  13. Perry A, Lambert P. Propionibacterium acnes: infection beyond the skin. Expert Rev Anti Infect Ther. 2011;9(12):1149–56. doi:10.1586/eri.11.137.

    Article  CAS  PubMed  Google Scholar 

  14. Yeranosian MG, Arshi A, Terrell RD, Wang JC, McAllister DR, Petrigliano FA. Incidence of acute postoperative infections requiring reoperation after arthroscopic shoulder surgery. Am J Sports Med. 2014;42(2):437–41. doi:10.1177/0363546513510686.

    Article  PubMed  Google Scholar 

  15. Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Should Elbow Surg. 2012;21(11):1534–41. doi:10.1016/j.jse.2012.01.006. This study retrospectively reviewed of a large series of prospectively gathered data on total shoulder arthroplasty. Long-term data demonstrates low rates of infection, with both staph species and P. acnes being among the most common organisms in the setting of postoperative infection.

    Article  Google Scholar 

  16. Singh JA, Sperling JW, Schleck C, Harmsen W, Cofield RH. Periprosthetic infections after shoulder hemiarthroplasty. J Should Elbow Surg. 2012;21(10):1304–9. doi:10.1016/j.jse.2011.08.067.

    Article  Google Scholar 

  17. Wall B, Nove-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007;89(7):1476–85.

    Article  PubMed  Google Scholar 

  18. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res. 2001;382:206–16.

    Article  PubMed  Google Scholar 

  19. Pottinger P, Butler-Wu S, Neradilek MB, et al. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012;94(22):2075–83. doi:10.2106/JBJS.K.00861.

    Article  PubMed  Google Scholar 

  20. Kwon YW, Kalainov DM, Rose HA, Bisson LJ, Weiland AJ. Management of early deep infection after rotator cuff repair surgery. J Should Elbow Surg. 2005;14(1):1–5.

    Article  Google Scholar 

  21. Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014;96(6):442–7. doi:10.2106/JBJS.M.00258. These authors demonstrated a high rate of P. acnes of 83 % infection in the setting of revision arthroplasty surgery for suspected infection. They also recommended using a total of ten PMNs in five high power fields (400×) to increase the sensitivity of infection detection of P. acnes to 72 %.

    Article  PubMed  Google Scholar 

  22. Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau P. The management of infection in arthroplasty of the shoulder. J Bone Joint Surg (Br). 2004;86(1):65–9.

    CAS  Google Scholar 

  23. Herrera MF, Bauer G, Reynolds F, Wilk RM, Bigliani LU, Levine WN. Infection after mini-open rotator cuff repair. J Should Elbow Surg. 2002;11(6):605–8. doi:10.1067/mse.2002.127302.

    Article  Google Scholar 

  24. Levy PY, Fenollar F, Stein A, et al. Propionibacterium acnes postoperative shoulder arthritis: an emerging clinical entity. Clin Infect Dis. 2008;46(12):1884–6. doi:10.1086/588477.

    Article  PubMed  Google Scholar 

  25. Kelly 2nd JD, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009;467(9):2343–8. doi:10.1007/s11999-009-0875-x.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Zhang AL, Feeley BT, Schwartz BS, Chung TT, Ma CB. Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment? J Shoulder Elbow Surg. 2014.

  27. Mirzayan R, Itamura JM, Vangsness Jr CT, Holtom PD, Sherman R, Patzakis MJ. Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am. 2000;82-A(8):1115–21.

    CAS  PubMed  Google Scholar 

  28. Holmberg A, Lood R, Morgelin M, et al. Biofilm formation by Propionibacterium acnes is a characteristic of invasive isolates. Clin Microbiol Infect. 2009;15(8):787–95. doi:10.1111/j.1469-0691.2009.02747.x.

    Article  CAS  PubMed  Google Scholar 

  29. Lorenzetti AJ, Wongworawat MD, Jobe CM, Phipatanakul WP. Cyanoacrylate microbial sealant may reduce the prevalence of positive cultures in revision shoulder arthroplasty. Clin Orthop Relat Res. 2013;471(10):3225–9. doi:10.1007/s11999-013-2854-5. Using iodine impregnated draping may not reduce P. acnes infection. These authors investigate the use of a cyanoacrylate microbial sealant to reduce the prevalence of positive cultures and P. acnes infection in revision shoulder arthroplasty compared to the traditional iodine-barrier drapes.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Dodson CC, Craig EV, Cordasco FA, et al. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Should Elbow Surg. 2010;19(2):303–7. doi:10.1016/j.jse.2009.07.065.

    Article  Google Scholar 

  31. Lutz MF, Berthelot P, Fresard A, et al. Arthroplastic and osteosynthetic infections due to Propionibacterium acnes: a retrospective study of 52 cases, 1995–2002. Eur J Clin Microbiol Infect Dis. 2005;24(11):739–44. doi:10.1007/s10096-005-0040-8.

    Article  PubMed  Google Scholar 

  32. Piper KE, Fernandez-Sampedro M, Steckelberg KE, et al. C-reactive protein, erythrocyte sedimentation rate and orthopedic implant infection. PLoS One. 2010;5(2):e9358. doi:10.1371/journal.pone.0009358.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Grosso MJ, Frangiamore SJ, Saleh A, et al. Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Should Elbow Surg. 2014;23(9):1277–81. doi:10.1016/j.jse.2013.12.023.

    Article  Google Scholar 

  34. Foruria AM, Fox TJ, Sperling JW, Cofield RH. Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Should Elbow Surg. 2013;22(5):620–7. doi:10.1016/j.jse.2012.07.017.

    Article  Google Scholar 

  35. Butler-Wu SM, Burns EM, Pottinger PS, et al. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol. 2011;49(7):2490–5. doi:10.1128/JCM.00450-11. P. acnes requires longer incubation times and medium than standard cultures. After the 13 days of incubation, 21 % of clinically unimportant P. acnes isolates were identified from arthroplasty revisions. However, a diagnosis of P. acnes would have been missed in 29 % of patients if the extended culture incubation had been applied only to the anaerobic culture media. Therefore, it is essential to hold the cultures for at least 13 days in both aerobic and anaerobic culture media.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Shannon SK, Mandrekar J, Gustafson DR, et al. Anaerobic thioglycolate broth culture for recovery of Propionibacterium acnes from shoulder tissue and fluid specimens. J Clin Microbiol. 2013;51(2):731–2. doi:10.1128/JCM. 02695-12.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  37. Berbari E, Mabry T, Tsaras G, et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2010;92(11):2102–9. doi:10.2106/JBJS.I.01199.

    Article  PubMed  Google Scholar 

  38. Trimble BS, Evers CJ, Ballaron SA, Young JM. Intraarticular injection of Propionibacterium acnes causes an erosive arthritis in rats. Agents Actions. 1987;21(3–4):281–3.

    Article  CAS  PubMed  Google Scholar 

  39. Kooijmans-Coutinho MF, Markusse HM, Dijkmans BA. Infectious arthritis caused by Propionibacterium acnes: a report of two cases. Ann Rheum Dis. 1989;48(10):851–2.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  40. Schaeverbeke T, Lequen L, de Barbeyrac B, et al. Propionibacterium acnes isolated from synovial tissue and fluid in a patient with oligoarthritis associated with acne and pustulosis. Arthritis Rheum. 1998;41(10):1889–93. doi:10.1002/1529-0131(199810)41:10<1889::AID-ART23>3.0.CO;2-F.

    Article  CAS  PubMed  Google Scholar 

  41. Levy O, Iyer S, Atoun E, et al. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Should Elbow Surg. 2013;22(4):505–11. doi:10.1016/j.jse.2012.07.007. There is significant controversy if P. acnes is the cause of arthrosis in the glenohumeral joints. These authors obtained aspirates and biopsy tissue from 55 shoulders undergoing shoulder arthroplasty for arthritis without any evidence of infection. They discovered that 41.8 % of samples were positive for P. acnes infection prior to the implantation of the arthroplasty components.

    Article  Google Scholar 

  42. Crane JK, Hohman DW, Nodzo SR, Duquin TR. Antimicrobial susceptibility of Propionibacterium acnes isolates from shoulder surgery. Antimicrob Agents Chemother. 2013;57(7):3424–6. doi:10.1128/AAC. 00463-13.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  43. Furustrand Tafin U, Corvec S, Betrisey B, Zimmerli W, Trampuz A. Role of rifampin against Propionibacterium acnes biofilm in vitro and in an experimental foreign-body infection model. Antimicrob Agents Chemother. 2012;56(4):1885–91. doi:10.1128/AAC. 05552-11.

    Article  PubMed Central  PubMed  Google Scholar 

  44. Strickland JP, Sperling JW, Cofield RH. The results of two-stage re-implantation for infected shoulder replacement. J Bone Joint Surg (Br). 2008;90(4):460–5. doi:10.1302/0301-620X.90B4.20002.

    Article  CAS  Google Scholar 

  45. Klatte TO, Junghans K, Al-Khateeb H, et al. Single-stage revision for peri-prosthetic shoulder infection: outcomes and results. Bone Joint J. 2013;95-B(3):391–5. doi:10.1302/0301-620X.95B3.30134. Single-stage revision for an infected shoulder arthroplasty. Klatte et al. reviewed their series of one-stage revisions of arthroplasties infected with both Staph species and P. acnes and reported a 94 % successful eradication rate.

    Article  CAS  PubMed  Google Scholar 

  46. Millett PJ, Yen YM, Price CS, Horan MP, van der Meijden OA, Elser F. Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res. 2011;469(10):2824–30. doi:10.1007/s11999-011-1767-4.

    Article  PubMed Central  PubMed  Google Scholar 

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Conflict of Interest

David Saper, Nina Capiro, and Richard Ma declare that they have no conflict of interest.

Xinning Li reports compensation from Tornier and Mitek Sports Medicine, outside the submitted work.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Boston Medical Center, Department of Orthopaedic Surgery, Boston University School of Medicine, 720 Harrison Avenue - Suite # 808, Boston, MA, 02118, USA

    David Saper, Nina Capiro & Xinning Li

  2. Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, MO, USA

    Richard Ma

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  1. David Saper
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  2. Nina Capiro
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Correspondence to Xinning Li.

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This article is part of the Topical Collection on Shoulder Surgery: Complications

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Saper, D., Capiro, N., Ma, R. et al. Management of Propionibacterium acnes infection after shoulder surgery. Curr Rev Musculoskelet Med 8, 67–74 (2015). https://doi.org/10.1007/s12178-014-9256-5

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