Acne crème to Reduce Propionibacterium Acnes Load in Primary Shoulder Surgery

Can Propionibacterium Acnes Load in Primary Shoulder Surgery be Reduced With Preoperative Application of a Benzoylperoxid/Miconazolnitrat crème Additional to Standard Antibiotic Prophylaxis

60 patients undergoing first time open shoulder surgery (Latarjet, prosthesis) will be prospectively included in this study. The investigators will do a randomized controlled trial, choosing with a single-blinded protocol 30 patients for local therapy and other 30 patients as the control group without any treatment preoperative. In the preoperative consultation 30 patients will get Acne Crème Plus (Benzoylperoxid and Miconazolnitrat) to apply until operation (on average 7 days) after receiving written consent. The application should be done daily in the evening on the planned operative side covering the skin from the nipple-areola complex laterally to the medial margin of the scapula and from a horizontal line through the nipple-areola complex cranially over the shoulder and dorsally to the spina scapulae. 30 patients will be included in the control group. Those patients will not get the local therapy in the preoperative consultation but they will need to give written consent for taking swabs for culture samples pre- and intraoperative. In the operation room there will be done from each of the 60 patients a superficial skin swab before doing disinfection, a swab of the subcutaneous layer and a swab of the deep layer (joint capsule). All the three swabs from each of the 60 patients will be sent to Unilabs, Labor für Medizinische Analytik AG, Dübendorf, Switzerland to streak on agar plates to cultivate under anaerobic conditions for 14 days. Propionibacterium acnes will be identified by use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

Study Overview

• Status: Completed
• Conditions: Shoulder Infections
• Intervention / Treatment: Drug: Acne Crème Plus

Detailed Description

According to recent studies, Propionibacterium acnes is found in 30% of patients with no preliminary shoulder operation and without obvious signs of infection. This bacterium is supposed to be the main pathogen causing shoulder infections. As it resides in the subcutaneous layer, many antiseptic and antibiotic agents that affect other layers fail to prevent infections. When administering antibiotics to reduce infections due to Propionibacterium acnes, cross-resistances to various antibiotics are created. Therefore, the investigators aim to investigate the efficacy of a local combination therapy without antibiotics (Benzoylperoxid and Miconazolnitrat) to reduce the presence of Propionibacterium acnes in patients first time undergoing open shoulder surgery. The investigators will also demonstrate the rate of positive cultures for Propionibacterium acnes in different layers regarding gender and age of patients. To best knowledge, no randomized controlled trials investigating the efficacy of Benzoylperoxid and Miconazolnitrat for reduction of Propionibacterium acnes in patients undergoing first time open shoulder surgery exist in the literature. However, in 1989 a clinical trial could demonstrate a 66% reduction of inflammatory acne lesions by applying a lotion containing Benzoylperoxid and Miconazol.

The investigators suppose that the patients with the local therapy (therapy group) show fewer positive samples than the patients of the control group as the combination of Benzoylperoxid and Miconazolnitrat (Widmer Acne Crème Plus, approval number 47033, Swissmedic) is used in the therapy of acne where Propionibacterium acnes is the major pathogen. By decreasing the presence of Propionibacterium acnes, infections and revision surgeries could be reduced as well. The investigators expect a higher rate of positive cultures from the subcutaneous layer compared to the superficial and to the deep layer. The investigators await more positive cultures in men than in women as men show a higher density of the glands in the subcutaneous layer where Propionibacterium acnes is linked to. For the same reason, the investigators suppose also a higher number of positive culture samples in younger patients (≤40 years) than in older patients (>40 years).

60 patients undergoing first time open shoulder surgery (Latarjet, prosthesis) will be prospectively included in this study. The investigators will do a randomized controlled trial, choosing with a single-blinded protocol 30 patients for local therapy and other 30 patients as the control group without any treatment preoperative. In the preoperative consultation 30 patients will get Acne Crème Plus (Benzoylperoxid and Miconazolnitrat) to apply until operation (on average 7 days) after receiving written consent. The application should be done daily in the evening on the planned operative side covering the skin from the nipple-areola complex laterally to the medial margin of the scapula and from a horizontal line through the nipple-areola complex cranially over the shoulder and dorsally to the spina scapulae. 30 patients will be included in the control group. Those patients will not get the local therapy in the preoperative consultation but they will need to give written consent for taking swabs for culture samples pre- and intraoperative. In the operation room there will be done from each of the 60 patients a superficial skin swab before doing disinfection, a swab of the subcutaneous layer and a swab of the deep layer (joint capsule). All the three swabs from each of the 60 patients will be sent to Unilabs, Labor für Medizinische Analytik AG, Dübendorf, Switzerland to streak on agar plates to cultivate under anaerobic conditions for 14 days. Propionibacterium acnes will be identified by use of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The number of positive culture samples from the therapy group will be compared with the number of positive culture samples from the control group.

Determination of Sample Size was done by performing a power analysis using www.clincalc.com, a sample size calculator placed at disposal by Sean P. Kane (clinical pharmacist, assistant professor at Rosalind Franklin University of Medicine and Science, North Chicago and advocate of evidence-based medicine). The study groups are two independent groups as they receive different treatments. The primary endpoint is dichotomous. The anticipated incidence of the therapy group is defined as 30%, the incidence of the control group is supposed to be 3-5% and the enrolment ratio is 1. The probability of a type-I-error is 0.05. With obtaining a power of 80%, between 56 and 70 participants are needed for the study according to the sample size calculator.

Recent studies could show that 30% of the patients without any obvious signs for infection and no preliminary operation have positive culture samples for Propionibacterium acnes, the investigators expect this result as well. The investigators suppose that the patients with the local therapy (therapy group) show fewer positive samples than the patients of the control group as the combination of Benzoylperoxid and Miconazolnitrat is used in the therapy of acne where Propionibacterium acnes is the major pathogen. As it is known that Propionibacterium acnes resides in the subcutaneous layer, the investigators expect a higher rate of positive cultures from the subcutaneous layer compared to the superficial and to the deep layer. The investigators expect more positive cultures in men than in women as men show a higher density of the glands in the subcutaneous layer where Propionibacterium acnes is linked to. The investigators suppose also a higher number of positive culture samples in younger patients (≤40 years) than in older patients (>40 years).

• Study Type: Interventional
• Enrollment (Actual): 60
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Switzerland
  • Zurich, Switzerland, 8008
    • University Hospital Balgrist

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients undergoing first time open shoulder surgery (Latarjet, prosthesis)
• Male and female patients
• Age > 18 years
• Competent German language skills
• Written informed consent as documented by signature (Appendix Informed Consent Form)

Exclusion Criteria:

• Previous enrollment into the current study,
• known or suspected non-compliance, drug or alcohol abuse,
• participation in another study with investigational drug within the 30 days preceding and during the present study,
• pregnancy or breast feeding (see chapter 3.7),
• preliminary shoulder surgeries,
• patients planned for an arthroscopic shoulder surgery,
• hypersensitivity to Benzoylperoxid or Miconazol,
• use of other acne preparations

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: SINGLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
NO_INTERVENTION: Control group; The participants of the control group will not get the local therapy in the investigator's preoperative consultation but they will need to give written consent for taking swabs for culture samples pre- and intraoperative.
EXPERIMENTAL: Therapy group; 30 patients will get Acne Crème Plus (Benzoylperoxid and Miconazolnitrat) to apply until operation (on average 7 days) after receiving written consent. The application should be done daily in the evening on the planned operative side covering the skin from the nipple-areola complex laterally to the medial margin of the scapula and from a horizontal line through the nipple-areola complex cranially over the shoulder and dorsally to the spina scapulae.	Drug: Acne Crème Plus; The study specific intervention product is a combination of Benzoylperoxid and Miconazolnitrat (Widmer Acne Crème Plus, 47033 Swissmedic) to apply daily in the evening on the skin from the nipple-areola complex laterally to the medial margin of the scapula and from a horizontal line through the nipple-areola complex cranially over the shoulder and dorsally to the spina scapulae. The application should be done regularly for 7 days before shoulder surgery. The study specific intervention product is authorized by Swissmedic for use in the treatment of acne and is used standardly in clinical practice.; Other Names: Widmer Acne Crème Plus, 47033 (Swissmedic)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Positive Propionibacterium acnes sample therapy group before therapy	Number of positive culture samples for Propionibacterium acnes in patients undergoing first time open shoulder surgery in the therapy group at the time point before application of therapy.	1 day
Positive Propionibacterium acnes sample control group before surgery	Number of positive culture samples for Propionibacterium acnes in patients undergoing first time open shoulder surgery in the control group at the time point before application of therapy in the therapy Group.	1 day
Change of positive Propionibacterium acnes sample therapy group after therapy	Number of positive culture samples for Propionibacterium acnes in patients undergoing first time open shoulder surgery in the therapy group after application of therapy.	Around 7 days
Change of positive Propionibacterium acnes sample control group intraoperative	Number of positive culture samples for Propionibacterium acnes in patients undergoing first time open shoulder surgery in the control group after application of therapy in the therapy group.	Around 7 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of positive Propionibacterium acnes in different layers	Rate of positive cultures for Propionibacterium acnes in different layers (superficial, subcutaneous, deep layer)	Around 7 days
Change of positive Propionibacterium acnes gender-related	Rate of positive cultures for Propionibacterium acnes in male versus female	Around 7 days
Change of positive Propionibacterium acnes age-related	Rate of positive cultures for Propionibacterium acnes in younger versus older patients	Around 7 days

Collaborators and Investigators

• Sponsor: Balgrist University Hospital
• Investigators: Principal Investigator: Samy Bouaicha, PD Dr.med., Balgrist University Hospital

Publications and helpful links

General Publications

• Padegimas EM, Lawrence C, Narzikul AC, Zmistowski BM, Abboud JA, Williams GR, Namdari S. Future surgery after revision shoulder arthroplasty: the impact of unexpected positive cultures. J Shoulder Elbow Surg. 2017 Jun;26(6):975-981. doi: 10.1016/j.jse.2016.10.023. Epub 2017 Jan 10.
• Achermann Y, Sahin F, Schwyzer HK, Kolling C, Wust J, Vogt M. Characteristics and outcome of 16 periprosthetic shoulder joint infections. Infection. 2013 Jun;41(3):613-20. doi: 10.1007/s15010-012-0360-4. Epub 2012 Nov 3.
• Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013 Apr;22(4):505-11. doi: 10.1016/j.jse.2012.07.007. Epub 2012 Sep 13.
• Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. doi: 10.1016/j.jse.2009.07.065. Epub 2009 Nov 1.
• Phadnis J, Gordon D, Krishnan J, Bain GI. Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics. J Shoulder Elbow Surg. 2016 Feb;25(2):304-10. doi: 10.1016/j.jse.2015.08.002. Epub 2015 Oct 9.

Study record dates

Study Major Dates

• Study Start (ACTUAL): November 1, 2018
• Primary Completion (ACTUAL): April 27, 2020
• Study Completion (ACTUAL): May 23, 2020

Study Registration Dates

• First Submitted: February 15, 2019
• First Submitted That Met QC Criteria: May 13, 2019
• First Posted (ACTUAL): May 14, 2019

Study Record Updates

• Last Update Posted (ACTUAL): June 9, 2020
• Last Update Submitted That Met QC Criteria: June 8, 2020
• Last Verified: June 1, 2020

More Information

Terms related to this study

• Keywords: gram positive bacteria; Benzoylperoxid and Miconazolnitrat
• Other Study ID Numbers: W728

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: There is no plan to make IPD.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No