Clin Orthop Relat Res (2023) 00:1-8

DOI 10.1097/CORR.0000000000002738

Basic Research

Next-generation Sequencing Results Require Higher Inoculum

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for Cutibacterium acnes Detection Than Conventional

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Anaerobic Culture
Diana Fernández-Rodrı́guez MD1,2, Jeongeun Cho BS1, Niosha Parvizi BS1,
Adam Z. Khan MD1 , Javad Parvizi MD, FRCS1, Surena Namdari MD1
stKpJaykxPO0dTmG52Wz9uWv8= on 06/24/2023

Received: 26 October 2022 / Revised: 16 April 2023 / Accepted: 22 May 2023 / Published online: 21 June 2023
Copyright © 2023 by the Association of Bone and Joint Surgeons

Abstract
Background Cutibacterium acnes has been described as
the most common causative microorganism in prosthetic
shoulder infections. Conventional anaerobic culture or
molecular-based technologies are usually used for this
purpose, but little to no concordance between these meth-
odologies (k = 0.333 or less) has been observed.
Questions/purposes (1) Is the minimum C. acnes load for
detection higher for next-generation sequencing (NGS)
than for anaerobic conventional culture? (2) What duration
of incubation is necessary for anaerobic culture to detect all
C. acnes loads?
Methods Five C. acnes strains were tested for this study:
Four strains were causing infection and were isolated from
surgical samples. Meanwhile, the other was a reference
strain commonly used as a positive and quality control in
microbiology and bioinformatics. To create inoculums

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from Zimmer. In addition, SN certifies ownership interest of Actabond, Aevumed, CLEU Diagnostics, Coracoid Solutions, HealthExl, MD Valuate,
MediFlix, Parvizi Surgical Innovations, SurgiWipe, and Tangen.

1
Rothman Orthopaedic Institute, Philadelphia, PA, USA
2
Plan de Estudios Combinados en Medicina (PECEM) MD/PhD, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico
City, Mexico

S. Namdari ✉, Rothman Orthopaedic Institute, 925 Chestnut Street, Philadelphia, PA 19107, USA, Email: Surena.namdari@rothmanortho.com

Copyright © 2023 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 2 Fernández-Rodrı́guez et al. Clinical Orthopaedics and Related Research®

with varying degrees of bacterial load, we began with a
standard bacterial suspension at 1.5 x 108 colony-forming
units (CFU)/mL and created six more diluted suspensions
(from 1.5 x 106 CFU/mL to 1.5 x 101 CFU/mL). Briefly, to
XcPwNfwdA02jL8IwmI9oyE6Ap+nPRE3GrPdJ5t9sQToC+rXW4P92yOvyEPfXNpHQwwjeaiq1uuQ8z0IHxYgGr/EGogc447WGXnYZ
agar plates and determined the minimum incubation time in
days required for CFU detection in all strains and loads
examined in this study. Growth detection and bacterial
CFU counting were performed by three laboratory per-

do so, we transferred 200 mL from the tube with the highest sonnel, with a high intraobserver and interobserver agree-
inoculum (for example, 1.5 x 106 CFU/mL) to the fol- ment (k > 0.80). A two-tailed p value below 0.05 was
lowing dilution tube (1.5 x 105 CFU/mL; 1800 mL of
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considered statistically significant.

diluent + 200 mL of 1.5 x 106 CFU/mL). We serially
continued the transfers to create all diluted suspensions. Six
tubes were prepared per strain. Thirty bacterial suspensions
were tested per assay. Then, 100 mL of each diluted sus-
pension was inoculated into brain heart infusion agar with
horse blood and taurocholate agar plates. Two plates were
used per bacterial suspension in each assay. All plates were
stKpJaykxPO0dTmG52Wz9uWv8= on 06/24/2023
Results Conventional cultures can detect C. acnes at a load
of 1.5 x 101 CFU/mL, whereas NGS can detect bacteria
when the concentration was higher, at 1.5 x 102 CFU/mL.
This is represented by a lower positive detection proportion
(73% [22 of 30]) for NGS than for cultures (100% [30 of
30]); p = 0.004). By 7 days, anaerobic cultures were able to
detect all C. acnes loads, even at the lowest concentrations.

incubated at 37°C in an anaerobic chamber and assessed for
growth after 3 days of incubation and daily thereafter until
positive or Day 14. The remaining volume of each bacterial
suspension was sent for NGS analysis to identify bacterial
DNA copies. We performed the experimental assays in
duplicate. We calculated mean DNA copies and CFUs for
each strain, bacterial load, and incubation timepoint
assessed. We reported detection by NGS and culture as a
qualitative variable based on the identification or absence
of DNA copies and CFUs, respectively. In this way, we
identified the minimum bacterial load detected by NGS and
culture, regardless of incubation time. We performed a
qualitative comparison of detection rates between meth-
odologies. Simultaneously, we tracked C. acnes growth on
Conclusion When NGS is negative and culture is positive
for C. acnes, there is likely a low bacterial load. Holding
cultures beyond 7 days is likely unnecessary.
Clinical Relevance This is important for treating physi-
cians to decide whether low bacterial loads necessitate
aggressive antibiotic treatment or whether they are more
likely contaminants. Cultures that are positive beyond
7 days likely represent contamination or bacterial loads
even below the dilution used in this study. Physicians may
benefit from studies designed to clarify the clinical im-
portance of the low bacteria loads used in this study at
which both methodologies’ detection differed. Moreover,
researchers might explore whether even lower C. acnes
loads have a role in true periprosthetic joint infection.

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MicroGenDx, personal fees in an amount of less than USD 10,000 from Jointstem, personal fees in an amount of less than USD 10,000 from
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of less than USD 10,000 from Smith & Nephew, research support in an amount of less than USD 10,000 from Stelkast, research support in an
amount of less than USD 10,000 from Stryker Orthopedics, research support in an amount of less than USD 10,000 from Synthes, research
support in an amount of less than USD 10,000 from TissueGene, research support in an amount of less than USD 10,000 from Tornier, and
research support in an amount of less than USD 10,000 from Orthospace. In addition, JP certifies ownership interest of Parvizi Surgical
Innovation and Subsidiaries, Hip Innovation Technology, Alphaeon/Strathsby Crown, Elute, Ceribell, Acumed, PRN-Veterinary, Illuminus,
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Ethical approval for this study was waived by the Thomas Jefferson University Institutional Review Board.

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 Volume 00, Number 00
Introduction
Infectious complications have been shown to occur in
0.2% to 1.5% and in 0.4% to 1.5% of patients un-
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dergoing primary THA and TKA, respectively [22]. In
fact, infection may be the leading cause of more than
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25% of revision procedures in those joints [3, 23].
Cutibacterium acnes is an anaerobic organism fre-
quently isolated from joint implants, especially but not
limited to the upper extremity [20]. Patients with peri-
prosthetic joint infection (PJI) secondary to C. acnes
present with vague clinical symptoms compared with
those with other pathogens, including pain, stiffness,
and less commonly, elevated serum and synovial bio-
stKpJaykxPO0dTmG52Wz9uWv8= on 06/24/2023
markers [1]. PJI by C. acnes is a diagnostic challenge
because of difficulties in bacterium isolation from
clinical samples and the interpretation of these results
[1, 4, 5, 19]. Hence, special attention was given to PJI by
C. acnes in the latest International Consensus Meeting
on PJI in 2018 [7].
Conventional anaerobic culture remains the gold stan-
dard for C. acnes isolation [2]. On the other hand, next-
generation sequencing (NGS) has emerged as a culture-
independent technology that enables the identification of
the microorganism’s DNA. This latter technique depicts a
promising role in light of polymicrobial communities and
fastidious and slow-growing microorganisms such as C.
acnes [15, 16]. However, recent studies have indicated
Fig. 1 Five C. acnes strains were diluted and assessed in parallel using NGS and
anaerobic conventional culture. ATCC 6919 = American Type Culture Collection 6919;
CSF = cerebrospinal fluid; CFU = colony-forming unit; NGS = next-generation
sequencing.
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C. acnes NGS Versus Culture 3
there are inconsistencies in the diagnosis of PJI by C. acnes
when using culture and culture-independent techniques
[10, 14, 16, 27]. This has been mainly attributed to the fact
there is little to no concordance between methodologies
(k = 0.333 or less [15, 16]).
Therefore, we asked: (1) Is the minimum C. acnes load
for detection higher for NGS than for anaerobic conven-
tional culture? (2) What duration of incubation is necessary
for anaerobic culture to detect all C. acnes loads?
Materials and Methods
Study Overview
We assessed C. acnes detection by NGS and anaerobic
conventional culture using strains isolated from surgical
samples (Fig. 1). To do so, we created bacterial suspen-
sions of each C. acnes strain at different known concen-
trations (1.5 x 106 colony forming units [CFU]/mL to 1.5
x 101 CFU/mL). Then, we tested each bacterial suspen-
sion with NGS and conventional anaerobic culture.
Simultaneously, we assessed the time of incubation nec-
essary to detect all C. acnes loads created in this study. We
performed the experimental assays in duplicate.
Our primary study goal was to determine the minimum
bacterial load detected by NGS and anaerobic conven-
tional culture. To achieve this, we used bacterial
 4 Fernández-Rodrı́guez et al.
suspensions at different known concentrations (Fig. 1).
The volume of each bacterial suspension was processed
for anaerobic conventional culture and NGS analysis.
Three laboratory personnel with a high intra- and in-
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terobserver agreement (k > 0.80) assessed growth;
meanwhile, NGS analysis was performed by a certified
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external facility. We reported detection by NGS and
culture as a qualitative variable based on the identification
or absence of DNA copies and CFUs, respectively. In this
way, we identified the minimum bacterial load detected
by NGS and culture, regardless of incubation time, and
performed a qualitative comparison of detection rates
between methodologies.
Our secondary study goal was to assess the incubation
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time necessary to detect C. acnes growth by anaerobic
conventional culture. All bacterial suspensions prepared
for this study (Fig. 1) were inoculated into brain heart in-
fusion agar with horse blood and taurocholate (Anaerobe
Systems) agar plates and incubated in an anaerobic atmo-
sphere at 37°C. Growth was evaluated at Day 3 and daily
thereafter until positive or Day 14. The time necessary for
C. acnes growth on agar plates was determined according
to the minimum incubation time in days required for CFU
detection in all strains and loads used in this study.
Strains of C. acnes
We tested five C. acnes strains in this study. We included the
reference strain American Type Culture Collection (ATCC)
6919. This C. acnes strain is used as a positive and quality
control in microbiology and bioinformatics [12]. In addition,
four strains isolated from surgical procedures were provided
from our biobank and used for this study. The number and
type of strains eligible for our study was limited because of
the growth requirements of C. acnes and its perception as a
contaminant. Thus, our study only included strains that were
confirmed as the causative microorganism of monobacterial
infections. We were able to include two isolates causing PJI
(knee and shoulder) and two more strains isolated from
surgical samples of the heart and vertebral column (cere-
brospinal fluid).
Culture Protocol
We used monobacterial cultures in agar plates to stir bac-
teria into a tube with Brucella broth (Anaerobe Systems)
using a loop. Bacteria in the broth were incubated in an-
aerobic conditions at 150 rpm and 37°C for 4 days. We
assessed growth (cloudy broth) at 4 days. Bacterial sus-
pensions were prepared using the cloudy broth and sterile
phosphate-buffered saline solution to achieve a 0.5
McFarland turbidity standard (1.5 x 108 CFU/mL).
Copyright © 2023 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
To create inoculums with varying degrees of bacterial
load, we began with the standard bacterial suspension (1.5
x 108 CFU/mL) and created six more diluted suspensions
(from 1.5 x 106 CFU/mL to 1.5 x 101 CFU/mL). To do so,
we transferred 200 mL from the tube with the highest
inoculum (1.5 x 106 CFU/mL) to the following dilution
tube (1.5 x 105 CFU/mL, containing 1800 mL of sterile
diluent and 200 mL of 1.5 x 106 CFU/mL). We serially
continued the transfers to create all diluted suspensions
(Fig. 1). Six tubes were prepared per strain. Thus, 30
testing tubes were prepared in total per assay. Then, 100
mL of each diluted suspension was inoculated and spread
into brain heart infusion agar with horse blood and taur-
ocholate agar plates. We inoculated two plates per di-
lution tube for each assay. Moreover, a vial with sterile
phosphate-buffered saline solution without inoculum was
used as negative control. All plates were incubated at
37°C in an anaerobic chamber.
Plates were examined after 72 hours and daily thereafter
until positive or Day 14. Colony morphology, hemolysis, and
the CFUs at each timepoint were assessed as qualitative
variables by three laboratory personnel (DFR, JC, and NP)
with high intraobserver and interobserver agreement (k >
0.80). Briefly, colony morphology was focused on the size
(diameter in millimeters), surface appearance (for example,
mucoid or wrinkled), shape (such as punctiform, circular, or
irregular), color, and hemolysis pattern [25]. Hemolysis was
graded according to the characteristics of the area surrounding
the CFUs: A clear area denoted complete hemolysis (beta), a
greenish area indicated incomplete hemolysis (alpha), and no
changes indicated nonhemolytic (gamma) strains [18].
We performed the experimental assays in duplicate. For
each assay, we tested 30 tubes (five strains and six bacterial
suspensions per strain), which were incubated in two agar
plates per tube and processed for NGS analysis (description
below).
We calculated mean DNA copies and CFUs for each
strain, bacterial load, and incubation timepoint that were
assessed. Then, we reported detection by NGS and culture
as a qualitative variable, based on the identification or ab-
sence of DNA copies and CFUs, respectively. In this way,
we identified the minimum bacterial load detected by NGS
and culture, regardless of incubation time. For our second
research question, C. acnes growth was tracked on agar
plates, and the time in days for positivity was recorded for
each bacterial suspension. Then, the minimum incubation
time required for CFU detection was identified, regardless of
strain and load assessed in this study.
NGS
The remaining volume of each bacterial suspension was
processed at the MicrogenDx facility for NGS analysis to
 Volume 00, Number 00
identify bacterial DNA copies. Each bacterial suspension
was mechanically lysed using the Qiagen TissueLyser
(Qiagen). Then, we spiked each sample with a positive
internal control to ensure the success of the extraction
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process. In addition, negative controls were run along with
samples to identify contamination associated with the ex-
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traction process. DNA was then extracted using a
KingFisher Flex Purification System (ThermoFisher
Scientific). DNA was amplified using forward and reverse
primers specific to regions flanking the 16S rRNA gene for
bacteria and the internal transcribed spacer gene for fungi
on a LightCycler 480 II (Roche Life Sciences) with the
following thermal cycling profile: 95°C for 5 minutes; 35
cycles of 94°C for 30 seconds, 52°C for 40 seconds, and
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72°C for 1 minute; and final extension at 72°C for 10 mi-
nutes. Amplified DNA was then pooled and run on the
Illumina MiSeq (Illumina Inc).
Ethical Approval
Our study was exempt from institutional review board
approval because we only used frozen bacterial strains and
did not collect or share clinical information or tissue
samples.
Statistical Analysis
Bacterial counts were performed by three laboratory per-
sonnel (DFR, JC, and NP), with high intraobserver and
interobserver agreement (k > 0.80). Herein, we report the
total CFUs at 3, 4, 5, 6, and 7 days of incubation. Cultures
were held until Day 14 to answer our secondary goal;
however, no changes were seen in the positivity rate or
CFU counts after Day 7.
After sequencing, we ran sample data through
MicroGen Dx’s bioinformatic pipeline consisting of
Q-score assessment, denoising (quality trimming and read
Fig. 2 DNA copies and CFUs per C. acnes load and strain were determined by NGS and conventional anaerobic culture,
respectively. ATCC 6919 = American Type Culture Collection 6919; CSF = cerebrospinal fluid; CFU = colony-forming unit; NGS
= next-generation sequencing.
Copyright © 2023 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
C. acnes NGS Versus Culture 5
merging, as well as chimera detection) and diversity anal-
ysis (operational taxonomic unit selection and taxonomic
assignment) using MicroGen Dx’s curated microbial
database.
Total bacterial CFUs and DNA copies are summarized
with a descriptive analysis. We calculated the mean and SD
for each bacterial suspension and timepoint assessed. Then,
positivity or detection by conventional anaerobic culture
and NGS was recorded for each bacterial suspension as a
qualitative variable, regardless of incubation time. Relative
and absolute frequencies are reported, and the positivity
rate was compared (conventional anaerobic culture versus
NGS) using the chi-squared test. A two-tailed p value be-
low 0.05 was considered statistically significant.
Results
Minimum C. acnes Load Detection, NGS Versus
Anaerobic Culture
Conventional cultures can detect C. acnes at a load of 1.5 x
101 CFU/mL, whereas NGS can detect this bacterium only
when the concentration was higher, at 1.5 x 102 CFU/mL
(Fig. 2). This was represented by a lower positive detection
proportion (73% [22 or 30]) for NGS than for cultures
(100% [30 of 30]); p = 0.004). For the ATCC 6919 and
knee isolate, NGS analysis could identify C. acnes in
bacterial suspensions as low as 1.5 x 102 CFU/mL.
However, DNA copies of cerebrospinal fluid and shoul-
der and heart isolates were detected in bacterial suspen-
sions at 1.5 x 103 CFU/mL and above.
Duration to Hold Cultures to Detect C. acnes
By Day 7, the most-diluted C. acnes suspension was
detected by conventional anaerobic cultures in all strains
(Fig. 3). In our observations on Day 3, concentrations of
 6 Fernández-Rodrı́guez et al.
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Fig. 3 The lowest dilution (CFU/mL) detected by conventional
anaerobic culture varied between strains and time of in-
cubation. ATCC 6919 = American Type Culture Collection 6919;
CSF = cerebrospinal fluid; CFU = colony-forming unit.
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1.5 x 10⁴ CFU/mL were detected in all strains. On Day 4,
we found growth in agar plates inoculated with bacterial
suspensions as low as 1.5 x 103 CFU/mL. On Day 5, agar
plates at 1.5 x 101 CFU/mL depicted growth only for the
ATCC 6919, cerebrospinal fluid, and heart isolates. After
6 days of incubation, growth was detected in concentra-
tions of 1.5 x 102 CFU/mL for the isolates causing knee and
shoulder PJI.
Discussion
PJI because of C. acnes is a diagnostic challenge for phy-
sicians [1, 4, 19]. Inconsistencies in the diagnosis of PJI
owing to C. acnes when using culture and culture-
independent techniques have been mainly attributed to
the fact that there is little to no concordance between
methods (k = 0.333 or less [15, 16]). In this study, we
demonstrated that a lower C. acnes load can be detected
using conventional anaerobic culture, which resulted in a
higher detection rate than NGS. When NGS results are
negative and culture is positive for C. acnes, there is
likely a low bacterial load. Seven days of incubation were
enough to detect all C. acnes strains, even at the lowest
concentration. Thus, holding cultures beyond 7 days is
likely unnecessary, and cultures that turn positive beyond
7 days likely represent contamination or bacterial loads
even below the dilutions used in this study.
Limitations
First, our experiments were performed in a controlled en-
vironment using bacterial suspensions with a known con-
centration. This is not the case in daily practice, and the
threshold for C. acnes bacterial load that leads to clinically
important PJI is unknown. Thus, the optimal dilution at
which C. acnes should be identified by culture or NGS and
acted upon clinically requires further investigation. Still, to
our knowledge, testing even lower concentrations may not
have a major clinical impact because studies performed in
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Clinical Orthopaedics and Related Research®
the last century suggested that perioperative PJI samples
may harbor at least 102 CFUs [24, 26].
Second, we were unable to perform the NGS analysis
immediately after the bacterial suspensions were prepared.
This could have influenced the quality of the genetic mate-
rial in the samples and affected the NGS results.
Nonetheless, the samples were processed for NGS analysis
no more than 12 hours after culture. Additionally,
molecular-based technologies are highly influenced by the
targeted sequence [13]. We did not assess other molecular-
based techniques that are different from sequencing the
hypervariable regions V1 to V2 in the 16S rRNA gene.
Based on the findings of Meisel et al. [13], it is plausible that
primers for variable regions that are different from V1 to V2
in the 16S rRNA gene will identify C. acnes by NGS only at
higher concentrations. However, the detection rate and
concordance with culture might be higher if we consider
whole-genome or RNA-based sequencing [9]. A similar
limitation arises regarding culture. We used a comprehen-
sive and straightforward protocol using semisolid culture
(conventional anaerobic culture) and did not consider other
culture-based techniques. Availability and easiness were key
factors for us when we designed the experimental assays
performed in this study, because it would facilitate the use of
our findings in other centers. However, even shorter in-
cubation times may be seen when more sophisticated pro-
tocols are used [11].
Finally, the clinical background of the isolates used in
this study is unknown. We worked with a reference strain
that is used as quality control in microbiology and bio-
informatics [12] and four clinical isolates from the bacteria
bank at our home institution. As mentioned, the number and
type of strains eligible for our study were limited because of
the complexity of C. acnes isolation and its perception as a
contaminant. The strains tested were confirmed to be caus-
ing monobacterial infections at the anatomic location from
which they were isolated (surgical samples). We noticed that
the strains may have been exposed to different environments
in the host, as evidenced by their morphologic distinctions
and growth patterns (Fig. 3). This means that, despite the
little clinical or genetic information available for these
strains, our study considered heterogenous clinical isolates,
which ultimately may be more representative of a physician´
s daily experience.
Minimum C. acnes Load Detection, NGS Versus
Anaerobic Cultures
Culture was highly sensitive in detecting C. acnes at all
levels of dilution in all strains, whereas NGS did not
identify C. acnes at all levels. Physicians finding a negative
NGS analysis and a positive culture for C. acnes should
consider a low bacterial load scenario. This is important for
 Volume 00, Number 00
treating physicians to decide whether low bacterial loads
necessitate aggressive antibiotic treatment or whether they
are more likely contaminants. Moreover, the inconsis-
tencies between methods may be the result of the bacterial
XcPwNfwdA02jL8IwmI9oyE6Ap+nPRE3GrPdJ5t9sQToC+rXW4P92yOvyEPfXNpHQwwjeaiq1uuQ8z0IHxYgGr/EGogc447WGXnYZ
load required for C. acnes detection. Similar to our
findings, a prior clinical study demonstrated that the NGS
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positive detection rate for C. acnes was lower than for
culture (2.5% versus 15%) [17]. Gaston et al. [8] showed
NGS detection could be as low as 67.1% for fastidious
microorganisms such as C. acnes. Still, if NGS is positive,
the suspicion toward contamination or low inoculums that
may not represent true PJI [5] can be reduced (NGS was
positive only at 1.5 x 103 CFU/mL). In addition, NGS
results may enable a clinician to make decisions in a shorter
stKpJaykxPO0dTmG52Wz9uWv8= on 06/24/2023
period, especially considering that laboratory personnel
may also deal with small colonies that can be easily missed
ahead of aerobic bacteria and fungi. Our study not only
replicated previous evidence, but also indicated the specific
bacterial loads at which conventional anaerobic culture and
NGS results may differ. Thus, the physician’s decision may
benefit from studies designed to clarify the clinical im-
portance of the low bacteria loads used in this study (1.5 x
103 to 1.5 x 101) and explore whether even lower C. acnes
loads can be found for true PJI.
Duration to Hold Cultures to Detect C. acnes
Our findings suggest that culture incubation longer than
7 days may lead to isolation of very low loads of C. acnes
that likely represent contamination or ultimately may not
mean true PJI. By contrast, Bossard et al. [2] and Schäfer
et al. [21] have suggested that surgical specimens should be
cultured for at least 7 days in patients in whom there is a high
suspicion of C. acnes infection. The differences from our
study may be the result of processing surgical samples with
an unknown bacterial load, which increased uncertainty that
was countered by a longer incubation time. The findings of
this and other studies [6, 8] suggest that longer culture in-
cubation may lead to isolation of very low loads of C. acnes
with little to no clinical relevance. Frangiamore et al. [6]
suggested that incubation for more than 10 days isolated
contaminants rather than infecting microorganisms. Thus,
limiting the incubation time may decrease the detection of
contaminants without compromising the yield of C. acnes
strains without a clear role in true PJI.
Conclusion
NGS and culture vary in their ability to detect C. acnes.
When there is lack of concordance between culture and NGS
for C. acnes identification, there are likely to be lower bac-
terial loads. Moreover, holding cultures beyond 7 days is
Copyright © 2023 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
C. acnes NGS Versus Culture 7
likely unnecessary. Cultures that are positive beyond 7 days
likely represent contamination or bacterial loads lower than
the concentrations tested in our study. Clinicians have a
challenge in deciding whether to act on these low-level
culture results, which may not represent true PJI. Future
studies should determine the clinical relevance of the low
bacteria loads tested in this study and explore whether even
lower C. acnes loads might be found for true PJI.
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