Reducing infection risk.
Before, during, and after surgery.

Before surgery: reduce avoidable risks

• Check for active infection, wounds, folliculitis, or dermatitis near the shoulder. Address smoking, inadequate nutrition, anemia, and diabetes control. Coordinate immunosuppressive medication changes with the prescribing clinician.
• When feasible, separate an ipsilateral corticosteroid injection and elective arthroplasty by at least three months.
• Screen the nares for MSSA and MRSA with enough time for treatment. For carriers, use prescribed mupirocin 2% to both anterior nares twice daily for the five days before surgery. A facility-approved intranasal povidone-iodine protocol within two hours of surgery is an alternative; routinely using both is unnecessary.
• The suggested home regimen combines five daily chlorhexidine 4% washes, beginning four days before surgery, with five benzoyl peroxide 5% applications beginning two days before surgery. See the complete schedule and product precautions.
• Avoid razor shaving. Clip hair at the facility only if needed. Do not routinely use oral doxycycline or another oral antibiotic for decolonization.

In the operating room: coordinated protection

IV antibiotic prophylaxis

• Cefazolin: 2 g IV within 60 minutes before incision, increased to 3 g for patients weighing 120 kg or more. For prolonged surgery with normal renal function, redose at four hours from initiation of the preoperative dose, or earlier for major blood loss under the anesthesia/pharmacy protocol.
• Known MRSA colonization or a relevant MRSA history: add weight-based vancomycin when indicated by the institutional pathway, generally 15 mg/kg IV using actual body weight. Begin sufficiently early to complete the infusion before incision. Do not add vancomycin routinely for every patient.
• Clarify the actual antibiotic reaction before substituting for cefazolin. A penicillin-allergy label alone does not necessarily preclude cefazolin. For a genuine cefazolin contraindication, follow the institutional vancomycin pathway; severe delayed beta-lactam reactions require separate allergy assessment.

Optional lavage before closure

Sterile dilute povidone-iodine lavage may be considered under the facility’s protocol—for example, 0.35% for three minutes followed by a saline rinse. Evidence comes mainly from hip and knee arthroplasty and is mixed; a shoulder-specific infection-prevention benefit remains uncertain. This is an optional adjunct, not a home wound-care treatment.

After surgery: avoid unnecessary treatment

• For uncomplicated outpatient cases, stop prophylactic antibiotics at closure. Where an institutional arthroplasty pathway uses postoperative IV prophylaxis, stop within 24 hours. Do not routinely add a take-home course of doxycycline, cephalexin, or cefadroxil.
• Apply a sealed sterile dressing and minimize handling. Change it aseptically when wet, loose, or saturated, and follow the specific dressing’s wear instructions.
• Showering can generally begin after 48 hours if the closure, dressing, and surgical instructions permit. Avoid soaking until the incision is healed.
• Do not apply benzoyl peroxide, hydrogen peroxide, chlorhexidine scrubs, or antibiotic ointment directly to the healing incision.
• Arrange prompt assessment for new or persistent drainage, spreading redness, fever, wound separation, or unexpectedly increasing pain.

What the research does—and does not—show

Revision surgery is a different situation

Previous shoulder infection, revision surgery, or suspected occult C. acnes infection requires a separate culture and antibiotic plan. Extended treatment and intrawound vancomycin should be individualized rather than presented as routine care for uncomplicated primary replacement. Prevention and treatment of an established infection are different clinical decisions.