The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Quantitative Real-Time Polymerase Chain Reaction May Serve as a Useful Adjunct to Conventional Culture in The Detection of Cutibacterium acnes in the Glenohumeral Joint: A Study of 100 Consecutive Patients

Document Type : RESEARCH PAPER

Authors
Matthew Como
Rajiv P. Reddy
Margaret L. Hankins
Gillian E. Kane
Dongzhu Ma
Peter G. Alexander
Kenneth L. Urish
Amin Karimi
Albert Lin
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
10.22038/abjs.2023.70190.3295
Abstract
Objectives: Synovial fluid or tissue culture is the current gold standard for diagnosis of infection, but 
Cutibacterium acnes (C. acnes) is a frequent cause of shoulder PJI and is a notoriously fastidious 
organism. The purpose of this study was to compare quantitative real-time polymerase chain reaction 
(qRT-PCR) to standard culture as a more rapid, sensitive means of identifying C. acnes from the 
glenohumeral joint. We hypothesized that qRT-PCR would be more effective than standard culture at 
identifying C. acnes and would have greater sensitivity and specificity for detecting infection.
Methods: This was a prospective observational study with 100 consecutive patients undergoing arthroscopic or 
open shoulder surgery with known positive and negative controls. Intraoperatively, synovial fluid and tissue was 
obtained for C. acnes qRT-PCR and results were blinded to the gold standard microbiology cultures.
Results: Clinical review demonstrated 3 patients (3%) with positive cultures, none of which were positive for C. 
acnes. Of the samples tested by the C. acnes qRT-PCR standard curve, 12.2% of tissue samples and 4.5% of fluid 
samples were positive. Culture sensitivity was 60.0%, specificity was 100.0%, PPV was 100.0%, and NPV was 
97.9%. C. acnes qRT-PCR standard curve sensitivity, specificity, PPV, and NPV was 60.0%, 90.3%, 25.0%, and 
97.7% respectively for tissue specimens and 0%, 95.2%, 0%, and 95.2% respectively, for fluid specimens. For 
combination of culture and tissue qRT-PCR, the sensitivity, specificity, PPV and NPV was 100%, 90.3%, 35.7%, 
and 100%, respectively.
Conclusion: We report that qRT-PCR for C. acnes identified the organism more frequently than conventional 
culture. While these findings demonstrate the potential utility of qRT-PCR, the likelihood of false positive results of 
qRT-PCR should be considered. Thus, qRT-PCR may be useful as an adjuvant to current gold standard workup of 
synovial fluid or tissue culture for the diagnosis of infection.
 Level of evidence: II
Keywords
Cutibacterium acnes
Periprosthetic joint infection
Polymerase chain reaction
Shoulder arthroplasty
Shoulder arthroscopy
Subjects
  1. Beekman PDA, Katusic D, Berghs BM, Karelse A, de Wilde L. One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg Br. 2010; 92(6):817-822. doi:10.1302/0301-620X.92B6.23045.
  2. Hudek R, Gohlke F. Endoprotheseninfektionen der Schulter. Orthopade. 2013; 42(7):552-560. doi:10.1007/s00132-012-2026-4.
  3. Sperling JW, Kozak TKW, Hanssen AD, Cofield RH. Infection after Shoulder Arthroplasty. Clin Orthop Relat Res. 2001 :( 382):206-16. doi: 10.1097/00003086-200101000-00028.
  4. Pauzenberger L, Grieb A, Hexel M, Laky B, Anderl W, Heuberer P. Infections following arthroscopic rotator cuff repair: incidence, risk factors, and prophylaxis. Knee Surg Sports Traumatol Arthrosc. 2017; 25(2):595-601. doi: 10.1007/s00167-016-4202-2.
  5. Atesok K, MacDonald P, Leiter J, McRae S, Stranges G, Old J. Postoperative deep shoulder infections following rotator cuff repair. World J Orthop. 2017; 8(8):612. doi:10.5312/WJO.V8.I8.612.
  6. Mayne AIW, Bidwai AS, Clifford R, Smith MG, Guisasola I, Brownson P. The incidence and causative organisms of infection in elective shoulder surgery. Shoulder Elbow. 2018; 10(3):179. doi:10.1177/1758573217711888.
  7. Saltzman MD, Marecek GS, Edwards SL, Kalainov DM. Infection after shoulder surgery. J Am Acad Orthop Surg. 2011; 19(4):208-218. doi:10.5435/00124635-201104000-00005.
  8. Patel A, Calfee RP, Plante M, Fischer SA, Green A. Propionibacterium acnes colonization of the human shoulder. J Shoulder Elbow Surg. 2009; 18(6):897-902. doi:10.1016/J.JSE.2009.01.023.
  9. Patel MS, Singh AM, Gregori P, Horneff JG, Namdari S, Lazarus MD. Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring? J Shoulder Elbow Surg. 2020; 29(9):1920-1927. doi:10.1016/J.JSE.2020.02.020.
  10. Hsu JE, Bumgarner RE, Matsen FA. Propionibacterium in Shoulder Arthroplasty: What We Think We Know Today. J Bone Joint Surg Am. 2016; 98(7):597-606. doi:10.2106/JBJS.15.00568.
  11. Elston MJ, Dupaix JP, Opanova MI, Atkinson RE. Cutibacterium acnes (formerly Proprionibacterium acnes) and Shoulder Surgery. Hawaii J Health Soc Welf. 2019; 78(11 Suppl 2):3-5
  12. Dodson CC, Craig E v., Cordasco FA, et al. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg. 2010; 19(2):303-307. doi:10.1016/J.JSE.2009.07.065.
  13. Bossard DA, Ledergerber B, Zingg PO, et al. Optimal Length of Cultivation Time for Isolation of Propionibacterium acnes in Suspected Bone and Joint Infections Is More than 7 Days. J Clin Microbiol. 2016; 54(12):3043. doi:10.1128/JCM.01435-16.
  14. Schäfer P, Fink B, Sandow D, Margull A, Berger I, Frommelt L. Prolonged bacterial culture to identify late periprosthetic joint infection: a promising strategy. Clin Infect Dis. 2008; 47(11):1403-1409. doi:10.1086/592973.
  15. Jauregui JJ, Tran A, Kaveeshwar S, et al. Diagnosing a periprosthetic shoulder infection: A systematic review. J Orthop. 2021; 26:58-66. doi:10.1016/J.JOR.2021.07.012.
  16. Li C, Renz N, Trampuz A, Ojeda-Thies C. Twenty common errors in the diagnosis and treatment of periprosthetic joint infection. Int Orthop. 2020; 44(1):3-14. doi: 10.1007/s00264-019-04426-7.
  17. Wagner ER, Farley KX, Higgins I, Wilson JM, Daly CA, Gottschalk MB. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg. 2020; 29(12):2601-2609. doi:10.1016/j.jse.2020.03.049.
  18. Prinz J, Schmid B, Zbinden R, et al. Fast and Sensitive Multiplex Real-Time Quantitative PCR to Detect Cutibacterium Periprosthetic Joint Infections. J Mol Diagn. 2022; 24(6):666-673. doi:10.1016/J.JMOLDX.2022.03.003.
  19. Vandercam B, Jeumont S, Cornu O, et al. Amplification-based DNA analysis in the diagnosis of prosthetic joint infection. J Mol Diagn. 2008; 10(6):537-543. doi:10.2353/JMOLDX.2008.070137.
  20. Garrigues GE, Zmistowski B, Cooper AM, et al. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg. 2019; 28(6S):S8-S12. doi:10.1016/J.JSE.2019.04.034.
  21. Richards J, Inacio MCS, Beckett M, et al. Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty. Clin Orthop Relat Res. 2014; 472(9):2809-2815. doi:10.1007/S11999-014-3696-5.
  22. Baghdadi YMK, Maradit-Kremers H, Dennison T, et al. The hospital cost of two-stage reimplantation for deep infection after shoulder arthroplasty. JSES Open Access. 2017; 1(1):15. doi:10.1016/J.JSES.2017.02.001.
  23. Kennon JC, Songy CE, Marigi E, et al. Cost analysis and complication profile of primary shoulder arthroplasty at a high-volume institution. J Shoulder Elbow Surg. 2020; 29(7):1337-1345. doi:10.1016/j.jse.2019.12.008.
  24. Namdari S, Nicholson T, Abboud J, et al. Cutibacterium acnes is less commonly identified by next-generation sequencing than culture in primary shoulder surgery. Shoulder Elbow. 2020; 12(3):170. doi:10.1177/1758573219842160.
  25. Rao AJ, MacLean IS, Naylor AJ, Garrigues GE, Verma NN, Nicholson GP. Next-generation sequencing for diagnosis of infection: is more sensitive really better? J Shoulder Elbow Surg. 2020; 29(1):20-26. doi:10.1016/j.jse.2019.07.039.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 12, Issue 2
February 2024
Pages 102-107

  • Receive Date 10 May 2023
  • Revise Date 16 October 2023
  • Accept Date 16 December 2023