Does Application of Hydrogen Peroxide to the Dermis Reduce Incidence of Cutibacterium Acnes during Shoulder Arthroplasty: a randomized control trial.

INTRODUCTION Prosthetic Joint Infections (PJI) following shoulder arthroplasty are a major source of morbidity, and are most commonly caused by Cutibacterium acnes (C. acnes), a bacteria found concentrated in the dermis. Skin preparation using hydrogen peroxide has been shown to reduce positive cultures, however direct application to the dermis has not been investigated. The purpose of this study is to determine whether the application of hydrogen peroxide to the dermis affects the incidence of positive C. acnes cultures. METHODS A prospective, randomized control trial of patients undergoing primary shoulder arthroplasty by a single fellowship trained surgeon was performed between February to November 2020. Enrolled patients were randomized to either receive standard skin preparation and antibiotic prophylaxis with or without an additional application of hydrogen peroxide to the dermis following incision. Culture samples were taken from the skin, dermis, glenohumeral joint and air. Laboratory personnel and patients were blinded to randomization and all cultures were held for 14 days. Culture positivity rate along with culture site, day of culture positivity, and bacterial abundance of positive cultures were analyzed. Stratified analysis by gender and age of ≤69 years was also performed. RESULTS Sixty patients undergoing primary arthroplasty were randomized. The group receiving hydrogen peroxide (n=30) and the control group (n=30) were similar in age (71.1±7.1 vs 73.4±9.8; p=0.30), BMI (29.4±5.7 vs 28.5±6.0; p=0.57), gender (p=0.64), hand dominance (p=0.65) and surgery type (p=0.90). The overall rate of at least one positive culture was 18%. All positive cultures were C. acnes. The positive culture rate in the hydrogen peroxide (20%) and control group were similar (16%; p=1.00). There were no positive glenohumeral joint cultures and no wound complications. There was no significance difference in the culture site, day of culture positivity, and bacterial abundance. Stratification analysis by gender and age also demonstrated similar rates of C. acnes between study groups. CONCLUSION Standard skin preparation and antibiotic prophylaxis results in an overall low rate of skin and dermis culture positivity. The use of hydrogen peroxide after initial incision did not significantly alter the rate of positive C. acnes cultures during shoulder arthroplasty and did not increase wound complications.