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Starnes V, Duggan J, Hollingshead C. Fungal Prosthetic Joint Infection: A Case Series and Review of the Literature. Infect Dis Ther 2024; 13:1051-1065. [PMID: 38613628 PMCID: PMC11098995 DOI: 10.1007/s40121-024-00964-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/18/2024] [Indexed: 04/15/2024] Open
Abstract
INTRODUCTION Fungal prosthetic joint infections comprise less than 1% of prosthetic joint infections. Thus, little is known regarding optimal management. This study aims to characterize the microbiology, surgical and medical management, and outcomes for these complex infections. The objectives of this study were to assess the impact of surgical approach, antifungal treatment, fungal species, and time to onset of infection from initial surgery on patient outcomes. METHODS A retrospective record review over 12 years was performed in two health systems that included patients with a deep culture positive for a fungal isolate and the presence of a prosthetic joint. A literature review was performed using the same inclusion criteria. A total of 289 cases were identified and analyzed. RESULTS Candida was the most common isolate, and a two-stage revision was the most commonly employed surgical modality. The type of surgical intervention had a statistically significant relationship with outcome (P = 0.022). CONCLUSIONS Two-stage revision with extended antifungal therapy is preferred in these infections due to higher rates of positive outcomes.
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Affiliation(s)
- Victoria Starnes
- The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Joan Duggan
- Division of Infectious Diseases, The University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Caitlyn Hollingshead
- Division of Infectious Diseases, The University of Toledo College of Medicine and Life Sciences, Toledo, USA.
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Umbel BD, Haghverdian BA, Schweitzer KM, Adams SB. Diagnosis and Management of Infected Total Ankle Replacements. Orthop Clin North Am 2024; 55:285-297. [PMID: 38403374 DOI: 10.1016/j.ocl.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
As the number of primary total ankle replacements increases for treatment of end-stage ankle arthritis, failures are also expected to rise. Periprosthetic joint infection is among the causes of failures and has been reported to be as high as 5%. Diagnosis is usually made by a combination of clinical examination findings, imaging, laboratory, and microbiological workup. Management is generally separated into limb salvage or amputation. Limb salvage can be challenging and may involve a single versus staged approach. Options include revision arthroplasty or arthrodesis procedures (ankle versus tibiotalocalcaneal), and a multidisciplinary approach is sought to eradicate infection before definitive management.
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Affiliation(s)
- Benjamin D Umbel
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA.
| | - Brandon A Haghverdian
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
| | - Karl M Schweitzer
- Duke Orthopaedics of Raleigh, 3480 Wake Forest Road, Suite 204, Raleigh, NC 27609, USA
| | - Samuel B Adams
- Department of Orthopedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA
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Yang HY, Cheon JH, Jung DM, Seon JK. Comparison of outcomes between fungal and non-fungal periprosthetic joint infections in total knee arthroplasty. Bone Joint J 2023; 105-B:1286-1293. [PMID: 38035598 DOI: 10.1302/0301-620x.105b12.bjj-2023-0486.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims Fungal periprosthetic joint infections (PJIs) are rare, but their diagnosis and treatment are highly challenging. The purpose of this study was to investigate the clinical outcomes of patients with fungal PJIs treated with two-stage exchange knee arthroplasty combined with prolonged antifungal therapy. Methods We reviewed our institutional joint arthroplasty database and identified 41 patients diagnosed with fungal PJIs and treated with two-stage exchange arthroplasty after primary total knee arthroplasty (TKA) between January 2001 and December 2020, and compared them with those who had non-fungal PJIs during the same period. After propensity score matching based on age, sex, BMI, American Society of Anesthesiologists grade, and Charlson Comorbidity Index, 40 patients in each group were successfully matched. The surgical and antimicrobial treatment, patient demographic and clinical characteristics, recurrent infections, survival rates, and relevant risk factors that affected joint survivorship were analyzed. We defined treatment success as a well-functioning arthroplasty without any signs of a PJI, and without antimicrobial suppression, at a minimum follow-up of two years from the time of reimplantation. Results The fungal PJI group demonstrated a significantly worse treatment success rate at the final follow-up than the non-fungal PJI group (65.0% (26/40) vs 85.0% (34/40); p < 0.001). The mean prosthesis-free interval was longer in the fungal PJI group than in the non-fungal PJI group (6.7 weeks (SD 5.8) vs 4.1 weeks (SD 2.5); p = 0.020). The rate of survivorship free from reinfection was worse in the fungal PJI group (83.4% (95% confidence interval (CI) 64.1 to 92.9) at one year and 76.4% (95% CI 52.4 to 89.4) at two years) than in the non-fungal PJI group (97.4% (95% CI 82.7 to 99.6) at one year and 90.3% (95% CI 72.2 to 96.9) at two years), but the differences were not significant (p = 0.270). Cox proportional hazard regression analysis identified the duration of the prosthesis-free interval as a potential risk factor for failure (hazard ratio 1.128 (95% CI 1.003 to 1.268); p = 0.043). Conclusion Fungal PJIs had a lower treatment success rate than non-fungal PJIs despite two-stage revision arthroplasty and appropriate antifungal treatment. Our findings highlight the need for further developments in treating fungal PJIs.
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Affiliation(s)
- Hong-Yeol Yang
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Jae-Hyeok Cheon
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Dong-Min Jung
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Jong-Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
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Gonzalez MR, Clunk MJ, Acosta JI, Bedi ADS, Karczewski D, Lozano-Calderon SA. High Rates of Treatment Failure and Amputation in Modular Endoprosthesis Prosthetic Joint Infections Caused by Fungal Infections With Candida. Clin Orthop Relat Res 2023:00003086-990000000-01418. [PMID: 37988003 DOI: 10.1097/corr.0000000000002918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Fungal prosthetic joint infections (PJIs) are rare yet severe events associated with high rates of recurrent infection. Although bacterial PJIs associated with megaprostheses are known to be associated with higher rates of recurrence and amputation, little is known about fungal PJIs near megaprostheses. QUESTIONS/PURPOSES In patients with fungal megaprosthesis PJIs from one institutional registry, We asked: (1) what were the most common microorganisms isolated? (2) What were the reoperation-, revision-, and amputation-free survival rates 1 and 2 years after surgery? METHODS We conducted a retrospective analysis of megaprostheses in our institutional database. Between 2000 and 2022, 86 patients with a diagnosis of PJI after megaprosthesis implantation were surgically treated at our institution. We considered patients with microbiological cultures that were positive for fungal organisms and who had a minimum follow-up of 2 years from the initial treatment for PJI. Ten patients with fungal megaprosthesis PJIs were included. Although four patients had a follow-up shorter than 2 years, all reached one of the study endpoints at that earlier interval, and therefore were included. All included patients were treated between 2016 and 2022, and the diagnosis of PJI was made in accordance with the 2011 Musculoskeletal Infection Society criteria. Patients were treated with either debridement, antibiotics, and implant retention (DAIR), DAIR-plus (debridement, antibiotics, modular implant component exchange, and stem retention), or one-stage or two-stage revision. In general, DAIR was used for acute PJIs, while DAIR-plus was performed in patients with chronic PJIs who were deemed medically unfit to endure the high morbidity associated with removal of the stems. In cases of prior unsuccessful DAIR-plus or patients with fewer comorbidities, one-stage or two-stage revision was the main treatment approach. The median age at diagnosis was 67 years (range 32 to 84 years), 5 of 10 patients were female, and the median BMI was 31 kg/m2 (range 20 to 43 kg/m2). The median follow-up was 26 months (range 1 to 54 months). A Kaplan-Meier survival analysis was performed to calculate reoperation-, revision-, and amputation-free survival at 1 and 2 years from the index surgery for PJI. RESULTS The two most common organisms were Candida albicans (5 of 10 patients) and C.parapsilosis (3 of 10). Six of 10 patients had coinfection with a bacterial organism. One-year reoperation-free and revision-free survival were 35% (95% CI 9% to 64%) and 42% (95% CI 11% to 71%), respectively. Two-year reoperation-free and revision-free survival were 12% (95% CI 1% to 40%) and 14% (95% CI 1% to 46%), respectively. Amputation-free survival was 74% (95% CI 30% to 93%) at the 1-year interval and 40% at the 2-year interval (95% CI 7% to 73%). At the final follow-up interval, four patients had undergone amputations and four were being administered chronic antifungal suppression. CONCLUSION Megaprosthesis fungal PJIs are rare but devastating. Arthroplasty surgeons should consider treatment efficacy, which appears to be low across surgical strategies, and the patient's capacity to withstand it. A lower decision threshold for performing amputation may be considered in patients who require rapid infection control to initiate immunosuppressive treatments. Future studies should aim to compare the surgical and clinical outcomes of fungal PJIs with those of other etiologies while controlling for potential variables. Efforts should be made to establish multi-institutional collaborations to achieve larger study samples. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Marcos R Gonzalez
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marilee J Clunk
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Jose I Acosta
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Angad D S Bedi
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Karczewski
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Gonzalez MR, Bedi ADS, Karczewski D, Lozano-Calderon SA. Treatment and Outcomes of Fungal Prosthetic Joint Infections: A Systematic Review of 225 Cases. J Arthroplasty 2023; 38:2464-2471.e1. [PMID: 37172795 DOI: 10.1016/j.arth.2023.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Fungal prosthetic joint infections (PJIs) after a total joint arthroplasty are a rare, yet severe, occurrence not often reported in the literature. Unlike in bacterial PJIs, no clear consensus exists on fungal PJI optimal management. METHODS A systematic review was performed using the PubMed and Embase databases. Manuscripts were assessed for inclusion and exclusion criteria. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was applied for quality assessment. Individual demographic, clinical, and treatment information was retrieved from included manuscripts. RESULTS Seventy one patients who had a PJI of the hip and 126 of the knee were included. Infection recurrence occurred in 29.6% and 18.3% of patients with hip or knee PJI, respectively. Patients who had knee PJIs recurrence had a significantly higher Charlson Comorbidity Index (CCI). For knee PJIs, infection recurrence was more common in patients with Candida albicans (CA) PJIs (P = .022). Two-stage exchange arthroplasty was the most common procedure in both joints. Multivariate analysis found that CCI ≥ 3 was associated with an 18.5-fold increase in the risk of knee PJI recurrence (Odds ratio [OR] = 18.57). Additional risk factors for recurrence in the knee included CA etiology (OR = 3.56) and C-reactive protein at presentation ≥ 6 (OR = 6.54). Compared to debridement, antibiotics, and implant retention, 2-stage procedure was a protective factor for PJI recurrence in the knee (OR = 0.18). No risk factors were found in patients who had hip PJIs. CONCLUSION Treatment of fungal PJIs varies widely, but 2-stage revision is the most common. Risk factors for knee fungal PJI recurrence include elevated CCI, infection by CA, and high C-reactive protein at presentation.
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Affiliation(s)
- Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Angad D S Bedi
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel Karczewski
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Yang HY, Shin HH, Kim JW, Seon JK. The fate of fungal periprosthetic joint infection after total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2023; 47:2727-2735. [PMID: 37542541 DOI: 10.1007/s00264-023-05895-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/09/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE To demonstrate the clinical outcomes of patients with fungal periprosthetic joint infections (PJIs) after two-stage exchange arthroplasty combined with antifungal therapy. METHODS We retrospectively reviewed the outcomes of 41 patients with fungal PJIs after primary total knee arthroplasty (TKA) in a single centre from January 1999 to October 2017. During the first stage of resection arthroplasty, antifungal-impregnated cement spacers (AICSs) were implanted in all patients. After systemic antifungal treatment during the interval between the two surgeries, delayed reimplantation as part of a two-stage exchange protocol was performed when patients were clinically stable. We defined treatment success as a well-functioning arthroplasty without any signs of PJI after a minimum follow-up of two years without antimicrobial suppression. Successful treatment was confirmed by repeat negative cultures as well as a return of inflammatory markers to normal levels. RESULTS The treatment success rate was 63.4% at the final follow-up. Thirty-six of 41 patients (87.8%) met the criteria for second-stage revision after confirmation of complete infection control. The mean prosthesis-free interval was 6.6 months (range, 2.0-30.0 months). During follow-up after two-stage exchange arthroplasty, ten patients (27.7% of 36 patients) unfortunately experienced recurrence or relapse of infection after an average of 31.3 months (range, 2.7-135.6 months). The rate of survivorship free from reinfection was 94.4% at six months, 84.8% at one year, and 73.6% at two years. Cox proportional hazard regression analysis demonstrated that the prosthesis-free interval (HR = 1.016, p = 0.037) and mean length of antifungal treatment (HR = 0.226, p = 0.046) were potential risk factors for failure. CONCLUSION Fungal PJIs led to devastating clinical outcomes despite even two-stage revision arthroplasty with the use of AICSs and antifungal medications.
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Affiliation(s)
- Hong Yeol Yang
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, 322, Seoyang-ro, 58128, Hwasun, Republic of Korea
| | - Hyun Ho Shin
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, 322, Seoyang-ro, 58128, Hwasun, Republic of Korea
| | - Ji Won Kim
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, 322, Seoyang-ro, 58128, Hwasun, Republic of Korea
| | - Jong Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, 322, Seoyang-ro, 58128, Hwasun, Republic of Korea.
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Krampitz B, Steiner J, Trampuz A, Kühn KD. Voriconazole Admixed with PMMA-Impact on Mechanical Properties and Efficacy. Antibiotics (Basel) 2023; 12:antibiotics12050848. [PMID: 37237751 DOI: 10.3390/antibiotics12050848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND There are currently no recommendations to direct the optimal diagnosis and treatment of fungal osteoarticular infections, including prosthetic joint infections and osteomyelitis. Active agents (fluconazole; amphotericin B) are regularly applied per os or intravenously. Other drugs such as voriconazole are used less frequently, especially locally. Voriconazole is less toxic and has promising results. Local antifungal medication during primary surgical treatment has been investigated by implanting an impregnated PMMA cement spacer using intra-articular powder or by daily intra-articular lavage. The admixed dosages are rarely based on characteristic values and microbiological and mechanical data. The purpose of this in vitro study is to investigate the mechanical stability and efficacy of antifungal-admixed PMMA with admixed voriconazole at low and high concentrations. METHODS Mechanical properties (ISO 5833 and DIN 53435) as well as efficacy with inhibition zone tests with two Candida spp. were investigated. We tested three separate cement bodies at each measuring time (n = 3) Results: Mixing high dosages of voriconazole causes white specks on inhomogeneous cement surfaces. ISO compression, ISO bending, and DIN impact were significantly reduced, and ISO bending modulus increased. There was a high efficacy against C. albicans with low and high voriconazole concentrations. Against C. glabrata, a high concentration of voriconazole was significantly more efficient than a dose at a low concentration. CONCLUSIONS Mixing voriconazole powder with PMMA (Polymethylmethacrylate) powder homogeneously is not easy because of the high amount of dry voriconazole in the powder formulation. Adding voriconazole (a powder for infusion solutions) has a high impact on its mechanical properties. Efficacy is already good at low concentrations.
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Affiliation(s)
- Barbara Krampitz
- Medical Training and Science, Heraeus Medical GmhH, Hamburger Allee 50, 60486 Frankfurt, Germany
| | - Julia Steiner
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
| | - Andrej Trampuz
- Infectious Diseases, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Dieter Kühn
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
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Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature. Microorganisms 2022; 11:microorganisms11010084. [PMID: 36677376 PMCID: PMC9864285 DOI: 10.3390/microorganisms11010084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/15/2022] [Accepted: 12/24/2022] [Indexed: 12/29/2022] Open
Abstract
Fungal prosthetic joint infection (fPJI) is a rare complication; nonetheless, it represents a significant diagnostic and therapeutic challenge. There are no official guidelines on the most effective approach to identify and treat fPJIs. This systematic review aims to review the current literature on fPJI management and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Studies eligible for this systematic review were identified through an electronic systematic search of PubMed, Scopus, and Web of Science until 30 September 2022. Further references were obtained by cross-referencing. Sixty-three studies met the inclusion criteria, reporting on 372 cases of fPJI; such cases were described mostly in case reports and small case series with only a few larger cohort studies. Diagnosis of fPJI is challenging because of its chronic and indolent clinical course; it is further complicated by the technical difficulty of harvesting fungal cultures. A two-stage revision was the primary procedure in 239 (64.2%) patients whereas DAIR and one-stage approaches were reported in 30 (8.0%) and 18 (4.8 %) cases. In conclusion, our study highlights the heterogeneity of the reported treatments of fPJI, particularly in terms of medical management. With concern to a surgical approach, a two-stage revision arthroplasty is generally suggested, considering fPJI a delayed or late infection. The need for multicenter, prospective studies to provide standardized protocols and improve the treatment of fungal PJI clearly emerges.
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Gamaletsou MN, Rammaert B, Brause B, Bueno MA, Dadwal SS, Henry MW, Katragkou A, Kontoyiannis DP, McCarthy MW, Miller AO, Moriyama B, Pana ZD, Petraitiene R, Petraitis V, Roilides E, Sarkis JP, Simitsopoulou M, Sipsas NV, Taj-Aldeen SJ, Zeller V, Lortholary O, Walsh TJ. Osteoarticular Mycoses. Clin Microbiol Rev 2022; 35:e0008619. [PMID: 36448782 PMCID: PMC9769674 DOI: 10.1128/cmr.00086-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.
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Affiliation(s)
- Maria N. Gamaletsou
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Blandine Rammaert
- Université de Poitiers, Faculté de médecine, CHU de Poitiers, INSERM U1070, Poitiers, France
| | - Barry Brause
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Marimelle A. Bueno
- Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Manilla, Philippines
| | | | - Michael W. Henry
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aspasia Katragkou
- Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Ohio State University School of Medicine, Columbus, Ohio, USA
| | | | - Matthew W. McCarthy
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
| | - Andy O. Miller
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Zoi Dorothea Pana
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Ruta Petraitiene
- Weill Cornell Medicine of Cornell University, New York, New York, USA
| | | | - Emmanuel Roilides
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | | | - Maria Simitsopoulou
- Hippokration General Hospital, Aristotle University School of Health Sciences, Thessaloniki, Greece
- Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Nikolaos V. Sipsas
- Laiko General Hospital of Athens and Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Valérie Zeller
- Groupe Hospitalier Diaconesses-Croix Saint-Simon, Paris, France
| | - Olivier Lortholary
- Université de Paris, Faculté de Médecine, APHP, Hôpital Necker-Enfants Malades, Paris, France
- Institut Pasteur, Unité de Mycologie Moléculaire, CNRS UMR 2000, Paris, France
| | - Thomas J. Walsh
- Hospital for Special Surgery, Weill Cornell Medicine, New York, New York, USA
- Weill Cornell Medicine of Cornell University, New York, New York, USA
- New York Presbyterian Hospital, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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Periprosthetic Joint Infections Caused by Candida Species—A Single-Center Experience and Systematic Review of the Literature. J Fungi (Basel) 2022; 8:jof8080797. [PMID: 36012786 PMCID: PMC9410158 DOI: 10.3390/jof8080797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The aim of this study was to analyze the treatment results of fungal periprosthetic joint infections (PJI) caused by Candida species from a single orthopedic center and to compare them with reports from other institutions. Methods: Eight patients operated on from January 2014 to December 2021 met the inclusion criteria and were analyzed in terms of clinical outcomes. A systematic review of the literature identified 153 patients with Candida PJIs extracted from 12 studies according to the PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guidelines. Results: The success rate of the treatment in the case series was 50%. The most frequent pathogens were Candida albicans (three cases; 37.5%) and Candida parapsilosis (three cases; 37.5%). In one patient (12.5%), bacterial co-infection was noted, and in five patients (62.5%) significant risk factors of PJI were confirmed. The overall success rate on the basis of data collected for systematic review was 65.5%. A sub-analysis of 127 patients revealed statistically significant differences (p = 0.02) with a higher success rate for the knees (77.6%) than for the hips (58%). In 10 studies the analysis of risk factors was performed and among 106 patients in 77 (72.6%) comorbidities predispose to fungal PJI were confirmed. Bacterial co-infection was noted in 84 patients (54.9%). In 93 patients (60.7%) Candida albicans was the culprit pathogen, and in 39 patients (25.5%) Candida parapsilosis was the culprit pathogen. Based on these two most frequent Candida species causing PJI, the success rate of the treatment was statistically different (p = 0.03), and was 60.3% and 83.3%, respectively. The two-stage strategy was more favorable for patients with Candida parapsilosis infections (94.4% success rate) than the one-stage protocol (50% success rate; p = 0.02); as well as in comparison to the two-stage treatment of Candida albicans (65% success rate; p = 0.04). Conclusions: The analysis of the literature showed no differences in the overall success rate between one- and two-stage surgical strategies for all Candida species, but differed significantly comparing the two most frequent strains and concerning PJI localization. The frequent presence of bacterial co-infections makes it necessary to consider the additional administration of antibiotics in the case of fungal PJI.
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Candida periprosthetic infection of the knee: a systematic review of surgical treatments and clinical outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:899-907. [PMID: 35182240 DOI: 10.1007/s00590-022-03224-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Candida periprosthetic joint infections (PJIs) are a rare cause of prosthesis revision with severe consequences and challenging treatment. This study aims to produce a systematic analysis of types of treatment and outcome of knee Candida PJIs and their correlation with specific pathogen species. METHODS During April 2021, a literature search was performed according to PRISMA (Preferred Reporting Item for Systematic Reviews and Meta-Analyses) guideline. Reviewers used the Oxford Level of Evidence (LoE) and Methodological index for non-randomized studies (MINORS) score. Modal value of surgical, pharmacological treatment and outcome along with the correlation between types of treatment and outcome was calculated through Chi-square or Fisher exact test. RESULTS In total, 115 cases were collected through 51 articles, identifying 116 pathogens. Candida albicans was the most frequent pathogen. Analysis of LoE reveals 40 LoE 5 and 11 LoE 4. Thirteen patients underwent one-stage revision, 46 patients two-stage revision, 6 patients resection arthroplasty and arthrodesis, 4 patients long-term antifungal therapy, and 3 patients debridement with prosthesis retention. Global rate of success was 85.14%. Modal distribution revealed a preference for two-stage revision and Fluconazole in medical therapy. No difference in terms of fungal eradication was found among Candida species (p = 0.503) and for treatments except for two-stage revision and resection arthroplasty (p = 0.0125) or debridement with implant retention (p = 0.0498), and the rest of procedures and resection arthroplasty (0.0192). MINORS score was poor. CONCLUSIONS Analysis of the literature did not highlight any difference between types of surgical treatment and pathogens in terms of relapse or infection eradication. However, two-stage replacement may be preferred, allowing healing of infection in most cases.
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Lin YJ, Su T, Yang L, Chen GX. Mixed bacterial-fungal infection following total hip arthroplasty: A case report. Chin J Traumatol 2022; 25:32-36. [PMID: 34362649 PMCID: PMC8787236 DOI: 10.1016/j.cjtee.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 02/04/2023] Open
Abstract
Prosthetic infection is one of the severe postoperative complications of arthroplasty. Mixed bacterial-fungal prosthetic infection is rare but can be disastrous. This case was a 76-year-old female suffered from prosthetic infection following total hip replacement due to femoral neck fracture and underwent multiple debridements. The culture of periprosthetic tissue was bacteriologically sterile following the first debridement, while the Staphylococcus hominis was identified in the second debridement in the previous hospitalization where fungal infection had not been considered. Thus the pathogen spectrum of anti-infection therapy failed to contain fungus. Ultimately, the culture result of our sampled periprosthetic tissue during the third debridement was Candida albicans without bacterium in our hospital. The fungal prosthetic infection was successfully treated by a two-stage revision with antifungal drugs. Accurate diagnosis and standardized treatment is the key to the therapy of infection after hip arthroplasty, especially for mixed bacterial-fungal prosthetic infection.
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Enz A, Müller S, Mittelmeier W, Klinder A. Severe polymicrobial and fungal periprosthetic osteomyelitis persisting after hip disarticulations treated with caspofungin in risk patients: a case series. Ann Clin Microbiol Antimicrob 2021; 20:86. [PMID: 34972536 PMCID: PMC8720203 DOI: 10.1186/s12941-021-00490-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Periprosthetic fungal infections are considered rare and opportunistic infections. Treatment is difficult, and established standards do not yet exist. The choice of the appropriate antifungal drug might affect the patient outcome. CASES All the three cases presented showed polybacterial recurrent infection of the revision hip arthroplasty. All patients were of younger age, had multiple revisions of the endoprosthesis, each had a large partial femoral replacement greater than 40% of the femoral length, gentamycin-loaded cement, and a long anchoring distance of the used intramedullary stem. Due to the severe life-threatening infection with deep osteomyelitis, an amputation had to be performed. However, despite surgical intervention, the fungal dominated infection persisted. Finally, only the use of caspofungin allowed permanent infection control. CONCLUSION The polybacterial infection is driven by the symbiosis between fungi and bacteria. Therefore, eradication of the fungus is required to achieve elimination of the bacteria. Antimycotics of the echinocandin-class, such as caspofungin, may be considered as initial treatment.
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Affiliation(s)
- Andreas Enz
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany.
| | - Silke Müller
- Institute of Pharmacology and Toxicology, University medical center Rostock, Schillingallee 70, 18057, Rostock, Germany
| | - Wolfram Mittelmeier
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
| | - Annett Klinder
- Orthopedic Clinic and Policlinic, University Medical Center Rostock, Doberaner Str. 142, 18057, Rostock, Germany
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Baecker H, Frieler S, Geßmann J, Pauly S, Schildhauer TA, Hanusrichter Y. Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm : a prospective study. Bone Jt Open 2021; 2:671-678. [PMID: 34406077 PMCID: PMC8384437 DOI: 10.1302/2633-1462.28.bjo-2021-0002.r2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Aims Fungal periprosthetic joint infections (fPJIs) are rare complications, constituting only 1% of all PJIs. Neither a uniform definition for fPJI has been established, nor a standardized treatment regimen. Compared to bacterial PJI, there is little evidence for fPJI in the literature with divergent results. Hence, we implemented a novel treatment algorithm based on three-stage revision arthroplasty, with local and systemic antifungal therapy to optimize treatment for fPJI. Methods From 2015 to 2018, a total of 18 patients with fPJI were included in a prospective, single-centre study (DKRS-ID 00020409). The diagnosis of PJI is based on the European Bone and Joint Infection Society definition of periprosthetic joint infections. The baseline parameters (age, sex, and BMI) and additional data (previous surgeries, pathogen spectrum, and Charlson Comorbidity Index) were recorded. A therapy protocol with three-stage revision, including a scheduled spacer exchange, was implemented. Systemic antifungal medication was administered throughout the entire treatment period and continued for six months after reimplantation. A minimum follow-up of 24 months was defined. Results Eradication of infection was achieved in 16 out of 18 patients (88.8%), with a mean follow-up of 35 months (25 to 54). Mixed bacterial and fungal infections were present in seven cases (39%). The interval period, defined as the period of time from explantation to reimplantation, was 119 days (55 to 202). In five patients, a salvage procedure was performed (three cementless modular knee arthrodesis, and two Girdlestone procedures). Conclusion Therapy for fPJI is complex, with low cure rates according to the literature. No uniform treatment recommendations presently exist for fPJI. Three-stage revision arthroplasty with prolonged systemic antifungal therapy showed promising results. Cite this article: Bone Jt Open 2021;2(8):671–678.
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Affiliation(s)
- Hinnerk Baecker
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Sven Frieler
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany.,Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, USA.,Seattle Science Foundation, Seattle, Washington, USA.,Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Jan Geßmann
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Stephan Pauly
- Clinic for Special Orthopaedic and Trauma Surgery, Vivantes Auguste Viktoria Hospitals, Berlin, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Yannik Hanusrichter
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
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Enz A, Mueller SC, Warnke P, Ellenrieder M, Mittelmeier W, Klinder A. Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint-A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence. J Fungi (Basel) 2021; 7:404. [PMID: 34064002 PMCID: PMC8224054 DOI: 10.3390/jof7060404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/01/2023] Open
Abstract
The treatment of periprosthetic joint infections (PJI), and especially of re-infections, poses a highly complex problem in orthopaedic surgery. While fungal infections are rare, they present a special challenge. The therapy is often protracted and based on limited evidence. A total of 510 hip and knee revision surgeries were analysed for the occurrence of bacterial and fungal PJI. In patients with PJI, the duration of the hospital stay and the incidence of disarticulation of the infected joint were recorded. Out of the analysed revision arthroplasties, 43.5% were due to PJI. Monomicrobial infection occurred in 55.2%, dual microbial infection in 21.4%, and polymicrobial (≥3 different bacterial or fungal species) infection in 17.2% of the cases. Overall, Candida species were detected in 12.4% cases. Candida albicans was the main fungal pathogen. In 6.9% of cases, disarticulation of the joint was the only option to control PJI. The detection of polymicrobial infection more than doubled in follow-up revisions and there was a strong association between detection of Candida infection and disarticulation (OR 9.39). The majority of fungal infections were mixed infections of bacteria and Candida albicans. The choice of a biofilm penetrating antimycotic, e.g., caspofungin, together with a sufficient standard procedure for detection and surgical treatment can help to control the infection situation. Fungal infection often proves to be more difficult to treat than anticipated and is more frequent than expected.
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Affiliation(s)
- Andreas Enz
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Silke C. Mueller
- Institute of Pharmacology and Toxicology, University Medicine Rostock, 18057 Rostock, Germany;
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany;
| | - Martin Ellenrieder
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Wolfram Mittelmeier
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
| | - Annett Klinder
- Orthopaedic Clinic and Policlinic, University Medicine Rostock, 18057 Rostock, Germany; (M.E.); (W.M.); (A.K.)
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16
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Gross CE, Della Valle CJ, Rex JC, Traven SA, Durante EC. Fungal Periprosthetic Joint Infection: A Review of Demographics and Management. J Arthroplasty 2021; 36:1758-1764. [PMID: 33267978 DOI: 10.1016/j.arth.2020.11.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is one of the most feared complications of total joint arthroplasty (TJA). Although commonly the result of colonization by Staphylococcal species, a growing number of cases of PJI with fungal pathogens have been reported within the last decade. Although standard treatment with two-stage exchange mirrors that of bacterial PJI, the variability in virulence between fungal species makes for an unpredictable and challenging treatment course. METHODS A review of Pubmed and Scopus from years 2009 to 2019 was conducted with the search terms fungal, infection, Candida, arthroplasty, periprosthetic, and prosthesis. Publications were reviewed and screened, yielding data for 286 patients with fungal PJI in the hip, knee, shoulder, and elbow prosthetics. RESULTS Patient comorbidities generally included conditions impairing wound healing and immune response such as diabetes mellitus. Candida species were the most common fungal pathogens identified (85%); 30% had a concomitant bacterial infection. A two-stage exchange was most utilized, with a mean success rate of 65%. Antifungal impregnated spacers were utilized in 82 cases, with a comparatively high success rate (81%). Attempts at debridement with implant retention had substantially lower cure rates (15%). CONCLUSIONS Two-stage exchange is the favored approach to treating fungal PJI. Debridement with implant retention does not appear adequate to control infection, and retrieval of implanted materials should be prioritized. The use of antifungal impregnated spacers is an important area of ongoing research, with uncertainty regarding the type and quantity of antifungal agent to incorporate, although recent reports support the use of these agents.
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Affiliation(s)
- Christopher E Gross
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | | | - James C Rex
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | - Sophia A Traven
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
| | - Elizabeth C Durante
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC
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Kurmis AP. Eradicating Fungal Periprosthetic TKA "Super-infection": Review of the Contemporary Literature and Consideration of Antibiotic-Impregnated Dissolving Calcium Sulfate Beads as a Novel PJI Treatment Adjunct. Arthroplast Today 2021; 8:163-170. [PMID: 33855143 PMCID: PMC8024748 DOI: 10.1016/j.artd.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 12/17/2022] Open
Abstract
Fungal periprosthetic joint infections are an uncommon but potentially devastating complication of arthroplasty surgery. The concurrent presence of a coexistent bacterial pathogen—a so called “super-infection”—adds further complexity. With delays to definitive diagnosis and a large number of procedures before cure, the associated physical and psychological morbidity is considerable. Beyond this, the economic and resource burden can be substantial. This case report presents the successful rapid treatment of an atypical bacterial and fungal periprosthetic super-infection with two-stage revision surgery augmented with a commercially available dissolving calcium sulfate bead system permitting targeted local antifungal elution. While not the panacea for treatment, these beads provide another potentially useful tool in the atypical pathogen eradication armamentarium. Much research is still indicated to define the optimal care pathway for fungal periprosthetic super-infections.
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Affiliation(s)
- Andrew P. Kurmis
- Discipline of Medical Specialties, University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
- Corresponding author. Haydown Road, Elizabeth Vale, South Australia, 5112. Australia. Tel.: +61 8 8182 9000.
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Oenning S, Moellenbeck B, Gosheger G, Schmidt-Bräkling T, Schwarze J, Ackmann T, Schneider KN, Theil C. Fungal Periprosthetic Knee Joint Infection in a Patient with Metamizole-Induced Agranulocytosis. Arthroplast Today 2020; 6:726-730. [PMID: 32923558 PMCID: PMC7475080 DOI: 10.1016/j.artd.2020.07.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/17/2020] [Accepted: 07/25/2020] [Indexed: 12/25/2022] Open
Abstract
We present the case of a 55-year-old female patient with metamizole-induced agranulocytosis after total knee arthroplasty, leading to septic periprosthetic joint infections (PJIs). Owing to metamizole-induced agranulocytosis, the synovial leukocyte count was negative. Here, we discuss the diagnostic challenges evolving from sepsis and neutropenia in patients with suspected PJIs. We suggest an urgent surgical approach, mainly focusing on the clinical presentation preoperatively. Later, our patient developed candidemia and periprosthetic tissue samples were positive for Candida albicans. For fungal PJIs, long-term follow-up studies are lacking and therapeutic recommendations differ. Here, we present our therapeutic approach, including staged revision and 12 weeks of systemic antifungal therapy, and discuss recent findings regarding the therapy of fungal PJIs.
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Affiliation(s)
- Sebastian Oenning
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Burkhard Moellenbeck
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Georg Gosheger
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Tom Schmidt-Bräkling
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Jan Schwarze
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Thomas Ackmann
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Kristian Nikolaus Schneider
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
| | - Christoph Theil
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, Muenster, North Rhine-Westphalia, Germany
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19
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Jie K, Deng P, Cao H, Feng W, Chen J, Zeng Y. Prosthesis design of animal models of periprosthetic joint infection following total knee arthroplasty: A systematic review. PLoS One 2019; 14:e0223402. [PMID: 31581252 PMCID: PMC6776332 DOI: 10.1371/journal.pone.0223402] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The number of periprosthetic joint infections (PJI) after total knee arthroplasty (TKA) is increasing annually. Animal models have been used to clarify their clinical characteristics and the infection mechanism of pathogenic bacteria, However, since the prosthesis design of animal models is not uniform, it is difficult to simulate the environment of clinical PJI. OBJECTIVES To retrospect the progress on the prosthesis design of animal models of PJI after TKA and to summarize the criteria for evaluating a clinically representative model of PJI. METHODS This systematic review was reported on the basis of Systematic Reviews and Meta-Analyzes (PRISMA). Pubmed, EMbase, Cochrane Library, Web of Science, Wanfang Data and China National Knowledge Infrastructure were researched for animal models of PJI after TKA from database establishment to April 2019 according to Chinese and English retrieval words, including "periprosthetic joint infections and total knee arthroplasty," "periprosthetic joint infections and model," "periprosthetic joint infections and biofilm," and "total knee arthroplasty and model." RESULTS A total of 12 quantitative studies were enrolled in our study finally: 8 representative studies described prosthesis designs used in PJI animal models, 4 studies described prosthesis designs in non-infected animal models which were suitable for infection models. The major problems need to be dealed with were prosthesis, installation location, material, the function of separating the articular and medullary cavity, fixation manner, and the procedure of preserving the posterior cruciate ligament. CONCLUSION A highly representative design of the animal prosthesis of PJI should meet the following criteria: the surface of the prosthesis is smooth with the formation of biofilm, composed of titanium-6Al-4V or cobalt-chromium-molybdenum alloy; prosthesis can bear weight and is highly stable; and it can connect the joint cavity and medullary cavity simultaneously. To reach a more reliable conclusion, further experiments and improvements are required.
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Affiliation(s)
- Ke Jie
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Peng Deng
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Houran Cao
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Wenjun Feng
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Jinlun Chen
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
| | - Yirong Zeng
- The Third Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Baiyun District, Guangzhou, Guangdong Province, China
- * E-mail:
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Roberts SC, Zembower TR, Bolon MK, Kadakia AR, Gilley JH, Ko JH, Clark J, Ward-Fore S, Taiwo BO. Successful treatment of a Candida auris intra-articular infection. Emerg Microbes Infect 2019; 8:866-868. [PMID: 31179850 PMCID: PMC6566482 DOI: 10.1080/22221751.2019.1625287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
A 78-year-old woman with a long-term ankle spacer with antibacterials developed an intra-articular Candida auris infection. Treatment with systemic antifungal therapy plus an amphotericin B moulded cement spacer was successful.
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Affiliation(s)
- Scott C Roberts
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Teresa R Zembower
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA.,b Department of Pathology , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Maureen K Bolon
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Anish R Kadakia
- c Division of Orthopaedic Surgery , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Jasen H Gilley
- c Division of Orthopaedic Surgery , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Jason H Ko
- d Division of Plastic Surgery , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Jessica Clark
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Sharon Ward-Fore
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
| | - Babafemi O Taiwo
- a Division of Infectious Diseases , Northwestern University Feinberg School of Medicine , Chicago , IL , USA
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Theil C, Schmidt-Braekling T, Gosheger G, Idelevich EA, Moellenbeck B, Dieckmann R. Fungal prosthetic joint infection in total hip or knee arthroplasty. Bone Joint J 2019; 101-B:589-595. [DOI: 10.1302/0301-620x.101b5.bjj-2018-1227.r2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims Fungal prosthetic joint infections (PJIs) are rare and account for about 1% of total PJIs. Our aim was to present clinical and microbiological results in treating these patients with a two-stage approach and antifungal spacers. Patients and Methods We retrospectively reviewed our institutional database and identified 26 patients with positive fungal cultures and positive Musculoskeletal Infection Society (MSIS) criteria for PJI who were treated between 2009 and 2017. We identified 18 patients with total hip arthroplasty (THA) and eight patients with total knee arthroplasty (TKA). The surgical and antifungal treatment, clinical and demographic patient data, complications, relapses, and survival were recorded and analyzed. Results The median follow-up was 33 months. The success rate was 38.5% (10/26). Fluconazole resistance was found in 15%. Bacterial co-infection was common in 44% of patients for THA and 66% of patients with TKA. Mortality, reoperations, and treatment failure were common complications. Conclusion Treatment with a two-stage exchange is a possible option for treatment, although fungal infections have a high failure rate. Therapeutic factors for treatment success remain unclear. Cite this article: Bone Joint J 2019;101-B:589–595.
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Affiliation(s)
- C. Theil
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - T. Schmidt-Braekling
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - G. Gosheger
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - E. A. Idelevich
- Institute of Medical Microbiology, Muenster University Hospital, Muenster, Germany
| | - B. Moellenbeck
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
| | - R. Dieckmann
- Department of Orthopedics and Tumour Orthopedics, Muenster University Hospital, Muenster, Germany
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