TOPICAL PREPARATIONS FOR REDUCING CUTIBACTERIUM ACNES INFECTION IN SHOULDER SURGERY: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

The aim of this study was to evaluate the relative effects of topical preparations in reducing C. Acnes in shoulder surgery. The study protocol was registered with PROSPERO (CRD42022310312). We searched the MEDLINE, Embase, PsycINFO, and Cochrane Library databases in March 2022. Randomised controlled trials (RCTs) comparing any form of skin preparation in arthroscopic or open shoulder surgery were included. The primary outcome was reduction in the number of positive C. Acnes cultures. Secondary outcomes were adverse events related to application of topical preparations. We performed a network meta-analysis (NMA) to facilitate simultaneous comparison between multiple preparations across studies. We calculated differences between preparations using odds ratios (ORs) and their 95% confidence intervals (CIs). Risk of bias was assessed using the Cochrane risk-of-bias v2.0 tool. We found 16 RCTs (1,062 patients), of which 13 were suitable for NMA (927 patients). 4 RCTs were deemed as “low” risk-of-bias and 12 raised “some concerns”. Preparations included benzoyl peroxide (BPO), BPO combined with clindamycin, chlorhexidine gluconate (CHG), hydrogen peroxide (H2O2), povidone-iodine, and water with soap. Only BPO resulted in a significantly lower odds of a positive C. Acnes culture compared to placebo or soap and water (OR 0.14 95% CI 0.05-0.36). There was no statistically significant difference with all other skin preparations (BPO with clindamycin: OR 0.64 95% CI 0.07-5.50; CHG: OR 0.46 95% CI 0.09-2.53; H2O2: OR 0.52 95% CI 0.18-1.54). The only adverse events were skin irritation from BPO and CHG in a small number of reported cases. BPO is the most effective topical agent in reducing prevalence of C. Acnes in shoulder surgery. These results are limited by the combination of indirect and direct data. Future studies should focus on establishing optimal frequency and duration of pre-operative BPO to further reduce the burden of C. Acnes.