Benzoyl Peroxide is Cost-Effective for Preventing Infection by Cutibacterium Acnes in Arthroscopic Rotator Cuff Repair

Abstract

Purpose To evaluate the cost-effectiveness of benzoyl peroxide (BPO) in decreasing postoperative infections through a mathematical model in the setting of arthroscopic rotator cuff repair (RCR). Methods A break-even equation compared the costs associated with perioperative BPO use and postoperative infection following an arthroscopic RCR. The postoperative infection rate used for calculations was 0.28%, a value established in current literature. The break-even analysis produced a new infection rate, which defined how much BPO is needed to reduce the known infection rate in order for its prophylactic use to be cost-effective. The institution’s business office assessed the minimum itemized costs associated with the standard-of-care treatment of postoperative RCR infection. Sensitivity analysis was conducted to demonstrate how variability in the costs of BPO, in infection rates and in the cost of infection treatment affected the absolute risk reduction (ARR) and number needed to treat (NNT). Results Financial review yielded a minimum institutional cost of treating a postoperative infection following arthroscopic RCR of $24,991.31. Using the break-even formula to calculate the ARR at which the overhead costs of BPO and the treatment of infection were equal, BPO was economically viable if it decreased infection rate by 0.000734% (NNT = 1,361.92). This value was low because of the order of magnitude of difference between the costs of infection prevention when compared to the costs of treating postoperative infections. Conclusions This break-even analysis model suggests that the use of preoperative BPO in the setting of arthroscopic RCR is cost-effective for prevention of infection with Cutibacterium acnes , given the high cost of treating the infection versus the low cost of the solution. Clinical Relevance The economic feasibility of preoperative use of BPO in the setting of arthroscopic RCR could alter the standard of care.

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial

“…[1][2][3]16 C acnes is commonly cultured at the time of primary shoulder surgery, and benzoyl peroxide and hydrogen peroxide have both shown to be effective, and costeffective, in decreasing the burden of C acnes before shoulder surgery. 4,9,10,13,15,[17][18][19][20][21] Other methods for reducing the burden of C acnes at the time of primary shoulder arthroplasty have also been investigated, including the use of systemic antibiotics. 23 However, preoperative administration of systemic doxycycline in addition to cefazolin did not markedly reduce the rate of C acnes culture positivity in a randomized controlled trial.…”

“…In the orthopaedic literature, there is a growing body of evidence that supports the use of benzoyl peroxide as a safe, cost-effective, and effective method to reduce the burden of C acnes in patients undergoing shoulder surgery and thus potentially prevent C acnes infection. 4,9,10,13,16-20 However, there are concerns with using benzoyl peroxide including the logistical challenge of arranging the preoperative skin preparation, patient compliance with the preoperative skin preparation, and the possibility of a skin reaction in the surgical field that could result in a delayed procedure. 4,21…”

“…14,15 In the orthopaedic literature, there is a growing body of evidence that supports the use of benzoyl peroxide as a safe, cost-effective, and effective method to reduce the burden of C acnes in patients undergoing shoulder surgery and thus potentially prevent C acnes infection. 4,9,10,13,[16][17][18][19][20] However, there are concerns with using benzoyl peroxide including the logistical challenge of arranging the preoperative skin preparation, patient compliance with the preoperative skin preparation, and the possibility of a skin reaction in the surgical field that could result in a delayed procedure. 4,21 A recent prospective, blinded, and controlled trial by Chalmers et al 21 demonstrated that patients undergoing total shoulder arthroplasty (anatomic or reverse) who received hydrogen peroxide as part of their preoperative skin preparation had a lower rate of triple-positive cultures (skin, dermis, and joint) (0% versus 19%, P = .024) and positive joint cultures (10% versus 35%, P = .031) than the control group who received standard skin preparation.…”