Razi Amin, Ring David
Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX, USA.
Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX, USA.
J Shoulder Elbow Surg. 2025 Feb;34(2):617-625. doi: 10.1016/j.jse.2024.07.038. Epub 2024 Sep 17.
After shoulder surgery, infection is often diagnosed in the absence of an inflammatory host response (purulence, sepsis). In the absence of inflammation, the more appropriate diagnoses may be colonization or contamination. We reviewed the available data regarding culture of Cutibacterium acnes during primary and revision shoulder surgery and asked; 1) what is the prevalence of air, skin, and deep tissue colonization? 2) How often is an inflammatory host response associated with diagnosis of postoperative shoulder infection diagnosed on the basis of culture of C. acnes? 3) Is there any relation between culture of C. acnes and outcomes of shoulder surgery?
Three databases were searched for studies that address C. acnes and colonization or infection related to shoulder surgery. We analyzed data from 80 studies addressing the rates of C. acnes colonization/infection in patients undergoing shoulder surgery, evidence of an inflammatory host response, and relationship of C. acnes culture to surgery outcomes.
C. acnes is often cultured in the air in the operating room (mean 10%), the skin before preparation (mean 47%), and deep tissue in primary shoulder arthroplasty (mean 29%), arthroscopy (mean 27%), and other shoulder surgery (mean 21%). C. acnes was cultured from a mean of 39% of deep tissue samples during revision arthroplasty. C. acnes was believed to be the causative organism of a high percentage of the infections diagnosed after surgery, 39% in primary shoulder arthroplasties, 53% in revisions, 55% in arthroscopic surgeries, and 44% in a mixture of shoulder surgeries. Infection was nearly always diagnosed in the absence of an inflammatory host response. Documented purulence and sepsis were not specifically ascribed to C. acnes (rather than more virulent organisms such as S. aureus). Diagnosis of infection, or unexpected positive culture, with C. acnes during shoulder surgery is associated with outcomes comparable to shoulders with no bacterial growth.
The evidence to date supports conceptualization of C. acnes as a common commensal (colonization), and perhaps a frequent contaminant, and an uncommon cause of an inflammatory host response (infection). This is supported by the observations that 1) unexpected positive culture for C. acnes is not associated with adverse outcomes after shoulder surgery, and 2) diagnosed infection with C. acnes is associated with outcomes comparable to noninfected revision shoulder arthroplasty. We speculate that diagnosis of C. acnes infection might represent an attempt to account for unexplained discomfort, incapability or stiffness after technically sound shoulder surgery. If so, the hypothesis that stiffness and pain are host responses to C. acnes needs better experimental support.
肩部手术后，感染常被诊断为不存在炎症宿主反应（化脓、败血症）。在没有炎症的情况下，更合适的诊断可能是定植或污染。我们回顾了有关原发性和翻修性肩部手术期间痤疮丙酸杆菌培养的现有数据，并提出以下问题：1）空气、皮肤和深部组织定植的发生率是多少？2）基于痤疮丙酸杆菌培养诊断的术后肩部感染与炎症宿主反应相关的频率有多高？3）痤疮丙酸杆菌培养与肩部手术结果之间是否存在任何关系？
检索了三个数据库，以查找涉及痤疮丙酸杆菌以及与肩部手术相关的定植或感染的研究。我们分析了80项研究的数据，这些研究涉及肩部手术患者的痤疮丙酸杆菌定植/感染率、炎症宿主反应的证据以及痤疮丙酸杆菌培养与手术结果的关系。
在手术室空气中（平均10%）、术前皮肤（平均47%）以及原发性肩关节置换术（平均29%）、关节镜检查（平均27%）和其他肩部手术（平均21%）的深部组织中，经常培养出痤疮丙酸杆菌。在翻修关节置换术中，平均39%的深部组织样本培养出痤疮丙酸杆菌。痤疮丙酸杆菌被认为是手术后诊断出的高比例感染的病原体，在原发性肩关节置换术中占39%，在翻修术中占53%，在关节镜手术中占55%，在混合肩部手术中占44%。感染几乎总是在没有炎症宿主反应的情况下被诊断出来。记录的化脓和败血症并非特别归因于痤疮丙酸杆菌（而不是更具毒性的生物体，如金黄色葡萄球菌）。肩部手术期间因痤疮丙酸杆菌诊断出感染或意外培养阳性与无细菌生长的肩部手术结果相当。
迄今为止的证据支持将痤疮丙酸杆菌概念化为一种常见的共生菌（定植），也许是一种常见的污染物，以及炎症宿主反应（感染）的罕见原因。这得到了以下观察结果的支持：1）痤疮丙酸杆菌意外培养阳性与肩部手术后的不良结果无关；2）诊断为痤疮丙酸杆菌感染与非感染性翻修肩关节置换术的结果相当。我们推测，痤疮丙酸杆菌感染的诊断可能是为了解释技术上成功的肩部手术后无法解释的不适、功能障碍或僵硬。如果是这样，僵硬和疼痛是宿主对痤疮丙酸杆菌反应的假设需要更好的实验支持。
