Candida-induced prosthetic joint infection. A literature review including 72 cases and a case report

Propensity of Candida spp. prosthetic joint infection clinical isolates to form aggregates in synovial fluid and the clinical ramifications

BACKGROUND

Bacterial aggregation has been shown to occur in synovial fluid which are resistant to high concentrations of antibiotics. Yet the propensity of Candida spp. to form aggregates is unknown.

OBJECTIVE

To assess the ability of numerous Candida spp. to form synovial fluid aggregates and the clinical ramifications of the aggregates.

METHODS

Nine different Candidal prosthetic joint infection clinical isolates were evaluated for their ability to form aggregates at static and dynamic conditions and their resistance to high concentrations of amphotericin. Furthermore, the ability of tissue plasminogen activator (TPA) to disrupt the aggregates and enhance amphotericin activity was assessed.

RESULTS

The results show that all species of Candida spp. evaluated formed aggregates in synovial fluid under dynamic conditions that were resistant to amphotericin. Yet no aggregates formed in tryptic soy broth under any conditions or in synovial fluid under static conditions. As well, when TPA was combined with amphotericin there was a statistically significant decrease (p < .005) in the amount of colony forming units per mL for all Candidal species evaluated. Interestingly, for Candida krusei there was no colony forming units observed after exposure to TPA and amphotericin.

CONCLUSION

Our findings suggest that Candidal species form synovial fluid aggregates that are resistant to high dose amphotericin similar to those that occur with bacteria. However, the varying ability of the different Candida spp. to form hyphae and pseudohyphae compared to yeast cells may have direct impacts on the hardiness of the aggregates and thereby have clinical ramifications with respect to treatment durations.

High Rates of Treatment Failure and Amputation in Modular Endoprosthesis Prosthetic Joint Infections Caused by Fungal Infections With Candida

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/m 2 (range 20 to 43 kg/m 2 ). 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.

Incidence and Risk Factors for Acid-fast Bacillus/Fungal Culture Positivity in Primary, Conversion, and Revision Hip and Knee Arthroplasty

INTRODUCTION

Previous literature has reported minimal incidences of positive fungal/AFB cultures, questioning the routine use of these tests. With growing concern for excessive use, predictive factors for patients at higher risk for intraoperative AFB/fungal infections would help surgeons limit unnecessary testing. This study evaluates the positivity rate and predictive factors of positive fungal and/or acid-fast bacillus (AFB) cultures after primary, conversion, or revision hip and knee arthroplasty.

METHOD

Two hundred thirty-eight knee and hip procedures were done between January 2007 and 2022 where intraoperative AFB/fungal cultures were obtained. Procedures included primary total knee arthroplasty, primary total hip arthroplasty, conversion, first of two-stage, second of two-stage, irrigation and débridement polyexchange, and aseptic revision. Positivity rates of intraoperative AFB/fungal cultures were calculated as binomial exact proportions with 95% confidence intervals and are displayed as percentages. Univariable generalized linear mixed models estimated the unadjusted effects of demographics, individual comorbid conditions, and procedural characteristics on the logit of positive AFB/fungal cultures.

RESULTS

Two hundred thirty-eight knee and hip procedures recorded an overall positivity rate of 5.8% for intraoperative AFB/fungal cultures. Aseptic revisions showed the lowest rates of positivity at 3.6%, while conversions showed the highest rates of positivity at 14.3%. The positivity rates are highest among patients who are male (9.0%), of Hispanic origin (12.0%), with body mass index <30 (6.4%), and a Charlson Comorbidity Index <5 (6.1%). History of a prior infection in the same surgical joint showed statistically significant influence of odds of culture positivity with an odds ratio of 3.47 ( P -value: 0.039). Other demographic factors that we investigated including age, sex, race, ethnicity, body mass index, and Charlson Comorbidity Index did not show any notable influence on AFB/fungal positivity rates.

CONCLUSION

These results suggest utility in obtaining routine intraoperative AFB/fungal cultures, given the relatively high positivity and poor predictive factors.

Surgical procedures for the treatment of fungal periprosthetic infection following hip arthroplasty: a systematic scoping review

Background

There has been limited literature synthesizing the therapeutic effects of surgical procedures for fungal periprosthetic joint infection (PJI) following hip arthroplasty. The authors' current study aims to comprehensively review and analyze those relevant literature, and carefully make recommendations for future clinical practices.

Methods

Our current study was carried out in accordance with the PRISMA 2020 statement. Studies regarding the surgical management of fungal PJI following hip arthroplasty were collected via a thorough search of PubMed, Embase and Google scholar databases. The search was lastly performed in March 2023. Non-English language, reviews, articles with duplicated data, and articles without clear information about the type of fungal pathogens and treatment options were excluded. The authors evaluated their systematic review compliance by using AMSTAR 2 criteria and fell in moderate quality. Clinical outcomes of different surgical procedures were evaluated, and a binary logistic regression model was used to identify the risks associated with treatment failure. Data analyses were performed using the SPSS version 19.0.

Results

A total of 33 articles encompassing 80 patients with fungal PJI following hip arthroplasty were identified. Candida albicans was the most frequently isolated fungus (56.3%, 45/80). The overall treatment success was achieved in 71.1% (54/76) of the reported cases. Univariate analysis showed that the differences of success rate were not significant between publication periods, genders, ages, specimen collection methods, and fungal pathogens. Treatment success rate was 47.4% (9/19) in fungal PJI cases with bacterial co-infection, significantly lower than those without [vs. 79.0% (45/57), P=0.017]. The pooled success rate for surgical debridement, spacer implantation, resection arthroplasty, one-stage revision, and two-stage revision was 50.0% (4/8), 42.9% (3/7), 55.0% (11/20), 86.7% (13/15), and 88.5% (23/26), respectively, with significant differences between them (P=0.009). A binary logistic regression model showed that bacterial co-infection and surgical option were the two significant risk factors associated with treatment failure for fungal PJI following hip arthroplasty.

Discussion

Regarding the surgical treatment of fungal PJI following hip arthroplasty, patients with bacterial co-infection, and those treated with surgical procedures such as debridement, spacer implantation, and resection arthroplasty should be aware of the higher risks of failure. Nonetheless, future multiple-centre cohort studies are required to establish the optimal treatment.

Fungal Prosthetic Joint Infection: A Case Series and Review of the Literature

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.

Orthopedic Articular and Periarticular Joint Infections

Acute nontraumatic joint pain has an extensive differential. Emergency physicians must be adept at identifying limb and potentially life-threatening infection. Chief among these is septic arthritis. In addition to knowing how these joint infections typically present, clinicians need to be aware of host and pathogen factors that can lead to more insidious presentations and how these factors impact the interpretation of diagnostic tests.

Time-lapse mesoscopy of Candida albicans and Staphylococcus aureus dual-species biofilms reveals a structural role for the hyphae of C. albicans in biofilm formation

Polymicrobial infection with Candida albicans and Staphylococcus aureus may result in a concomitant increase in virulence and resistance to antimicrobial drugs. This enhanced pathogenicity phenotype is mediated by numerous factors, including metabolic processes and direct interaction of S. aureus with C. albicans hyphae. The overall structure of biofilms is known to contribute to their recalcitrance to treatment, although the dynamics of direct interaction between species and how it contributes to pathogenicity is poorly understood. To address this, a novel time-lapse mesoscopic optical imaging method was developed to enable the formation of C. albicans/S. aureus whole dual-species biofilms to be followed. It was found that yeast-form or hyphal-form C. albicans in the biofilm founder population profoundly affects the structure of the biofilm as it matures. Different sub-populations of C. albicans and S. aureus arise within each biofilm as a result of the different C. albicans morphotypes, resulting in distinct sub-regions. These data reveal that C. albicans cell morphology is pivotal in the development of global biofilm architecture and the emergence of colony macrostructures and may temporally influence synergy in infection.

Treatment and Outcomes of Fungal Prosthetic Joint Infections: A Systematic Review of 225 Cases

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.

The fate of fungal periprosthetic joint infection after total knee arthroplasty

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.

Comparative analysis of pathogen distribution in patients with fracture-related infection and periprosthetic joint infection: a retrospective study

BACKGROUND

The purpose of this study is to investigate the microbial patterns of periprosthetic joint infection (PJI) and fracture-related infection (FRI), and guide for the formulation of more accurate empirical antimicrobial regimens based on the differences in pathogen distribution.

METHODS

A comparative analysis of pathogen distribution was conducted between 153 patients (76 with PJI and 77 with FRI). Predicted analyses against isolated pathogens from two cohorts were conducted to evaluate the best expected efficacy of empirical antimicrobial regimens (imipenem + vancomycin, ciprofloxacin + vancomycin, and piperacillin/tazobactam + vancomycin).

RESULTS

Our study found significant differences in pathogen distribution between the PJI and FRI cohorts. Staphylococci (61.3% vs. 31.9%, p = 0.001) and Gram-negative bacilli (GNB, 26.7% vs. 56.4%, p < 0.001) were responsible for the majority of infections both in the PJI and FRI cohorts, and their distribution in the two cohorts showed a significant difference (p < 0.001). Multi-drug resistant organisms (MDRO) were more frequently detected in the FRI cohort (29.3% vs. 44.7%, p = 0.041), while methicillin-resistant coagulase-negative Staphylococci (MRCoNS, 26.7% vs. 8.5%, p = 0.002) and Canidia albicans (8.0% vs. 1.1%, p = 0.045) were more frequently detected in the PJI cohort. Enterobacter spp. and Acinetobacter baumannii were detected only in the FRI cohort (11.7% and 8.5%, respectively).

CONCLUSIONS

Staphylococci and GNB were responsible for the majority of infections in both PJI and FRI. Empirical antimicrobial therapy should focus on the coverage of Staphylococci in PJI and GNB in FRI, and infections caused by MDROs should be more vigilant in FRI, while the high incidence of MRCoNS in PJI should be noted, which could guide for the formulation of more accurate empirical antimicrobial regimens. Targeted therapy for FRI caused by A. baumannii and PJI caused by C. albicans needs to be further investigated. Our study reports significant differences in pathogen distribution between the two infections and provides clinical evidence for studies on the mechanism of implant-associated infection.

Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature

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.

Osteoarticular Mycoses

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.

Metagenomic next-generation sequencing assists the diagnosis treatment of fungal osteoarticular infections

Background

Fungal osteoarticular infection (FOI) is not commonly seen in clinical practice but proposes a great challenge to orthopedic surgeons. In this study, we aimed to investigate the risk factors, the clinical features, and surgical outcomes of FOI in our institution. Specifically, we aimed to explore the role of metagenomic next-generation sequencing (mNGS) in the diagnosis and treatment of FOI.

Methods

All the patients who were diagnosed and managed with FOI in our institution from January 2007 to December 2020 were retrospectively reviewed, including primary fungal implant-related infection, primary fungal osteomyelitis or arthritis, and fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. The potential risk factors and the clinical and surgical features were analyzed. The pathogen data were compared between culture and the mNGS test.

Results

A total of 25 patients were included, namely, 12 primary implant-related infections, 7 primary fungal osteomyelitis or arthritis, and 6 fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. Most cases had undergone multiple surgeries or long-term antibiotic treatment. Diagnosis was mainly based on microbial culture and the mNGS test. Optimization of culture methods and the use of mNGS assisted the diagnosis. Specifically, mNGS was performed in 12 patients, 5 of whom were culture-negative. In the remaining seven cases, mNGS demonstrated the same results as culture. Management of FOI was complicated as most patients required multiple surgeries followed by long-term antifungal treatment. In selected cases, antifungal-impregnated cement spacer retention can be an optional choice. The overall success rate was 100% (25/25) for our cohort.

Conclusion

We concluded that patients with comorbidities and a history of multiple surgeries or long-term antibiotics are under higher risk for FOI. Use of mNGS assists the diagnosis and treatment of FOI. Surgery combined with long-term antifungal treatment achieved satisfactory outcomes. In selected cases, antifungal-impregnated cement spacer retention can be an optional treatment choice.

The Pathogenic Yeast Candida parapsilosis Forms Pseudohyphae through Different Signaling Pathways Depending on the Available Carbon Source

Candida parapsilosis is an emerging fungal pathogen that primarily affects immunocompromised patients in hospitals. A significant risk factor is the use of implanted medical devices, which support the growth of biofilms composed of a mixture of individual yeast cells and chains of elongated pseudohyphal cells. The morphological switch between these two forms is triggered by cues from the environment, including nutrient availability and temperature. We examined how different nutrient sources affect the balance between yeast and pseudohyphae and found that cells grown in the presence of five- or six-carbon sugars form more pseudohyphae at 30°C than at 37°C. Conversely, cells grown on glycerol, a three-carbon polyalcohol, form more pseudohyphae at 37°C. Furthermore, we found that different regulators influence pseudohyphal growth on glucose at 30°C compared with those on glycerol at 37°C. In particular, cAMP signaling and the sirtuin deacetylase Hst1 were required for pseudohyphal growth on glycerol at 37°C but not on glucose at 30°C. Finally, we found that the carbon source on which C. parapsilosis is grown can influence its ability to establish an infection in a wax moth model. Overall, this study reveals that environmental conditions affect not only the extent of pseudohyphal growth but also which pathways and regulators govern pseudohyphal formation.

IMPORTANCECandida parapsilosis is one of the leading causes of hospital-acquired yeast infections and poses a significant risk to immunocompromised people. Two of its properties that contribute to infection are metabolic flexibility, to use a range of nutrients available in the host, and cellular dimorphism, to switch between round yeast cells and chains of elongated pseudohyphal cells. Uncovering the molecular mechanisms that regulate these processes could reveal new targets for antifungal drugs. We found that for C. parapsilosis, the balance between yeast and pseudohyphal cells depends on the nutrients available and the growth temperature. Moreover, these environmental changes can affect its ability to cause infections. Finally, we found that a potential sensor of the cell’s metabolic state, the sirtuin Hst1, contributes to pseudohyphal growth for cells grown on glycerol. These findings indicate that the shape and virulence of C. parapsilosis likely vary depending on its location in the host.

Candida periprosthetic joint infections - risk factors and outcome between albicans and non-albicans strains

Background

Despite its scarcity, fungal periprosthetic joint infection (PJI) is of great clinical relevance as diagnosis and treatment are highly challenging. Previous analyses focused on the treatment rather than the role of the causative fungal agent on clinical outcome. This is the largest study of its kind to evaluate Candida strain–dependent differences in patients with fungal PJI.

Methods

We retrospectively analyzed 29 patients who underwent surgical intervention due to Candida hip or knee PJI in our department from 2010 to 2018. PJI was defined according to IDSA, recurrent PJI according to modified Delphi consensus criteria. Statistical analysis was performed using t-test, chi-square test with Yates correction, and log rank test.

Results

Besides age and affected joint, no significant differences were found between Candida albicans and non-albicans PJI patients (75.83 versus 64.11 years, p = 0.012; 12 hip versus two knee cases, p = 0.013). Most patients received two- (27.59%) or three-stage exchange surgery (41.38%). There was a statistical trend towards an increase in surgery needed in non-albicans Candida PJI (2.92 versus 2.12; p = 0.103). After initial Candida PJI treatment, functional prosthesis implantation was achieved in 72.41% of all patients. At last follow-up, infection-free survival was at 26.79% in Candida albicans versus 72.00% in non-albicans PJI (p = 0.046).

Conclusions

In this study, we found infection-free survival rates to be significantly decreased in patients with albicans compared to non-albicans Candida PJI. While age and affected joint might play a confounding role, we speculate the causative pathogen to play a decisive role in disease progression.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00264-021-05214-y.

A New Antifungal-Loaded Sol-Gel Can Prevent Candida albicans Prosthetic Joint Infection

Fungal PJI is one of the most feared complications after arthroplasty. Although a rare finding, its high associated morbidity and mortality makes it an important object of study. The most frequent species causing fungal PJI is C. albicans. New technology to treat this type of PJI involves organic-inorganic sol-gels loaded with antifungals, as proposed in this study, in which anidulafungin is associated with organophosphates. This study aimed to evaluate the efficacy of an anidulafungin-loaded organic-inorganic sol-gel in preventing prosthetic joint infection (PJI), caused by Candida albicans using an in vivo murine model that evaluates many different variables. Fifty percent (3/6) of mice in the C. albicans-infected, non-coated, chemical-polished (CP)-implant group had positive culture and 100% of the animals in the C. albicans-infected, anidulafungin-loaded, sol-gel coated (CP + A)-implant group had a negative culture (0/6) (p = 0.023). Taking the microbiology and pathology results into account, 54.5% (6/11) of C. albicans-infected CP-implant mice were diagnosed with a PJI, whilst only 9.1% (1/11) of C. albicans-infected CP + A-implant mice were PJI-positive (p = 0.011). No differences were observed between the bone mineral content and bone mineral density of noninfected CP and noninfected CP + A (p = 0.835, and p = 0.181, respectively). No histological or histochemical differences were found in the tissue area occupied by the implant among CP and CP + A. Only 2 of the 6 behavioural variables evaluated exhibited changes during the study: limping and piloerection. In conclusion, the anidulafungin-loaded sol-gel coating showed an excellent antifungal response in vivo and can prevent PJI due to C. albicans in this experimental model.

Candidemia and Invasive Candidiasis

Invasive candidiasis (IC) is a collective term that refers to a group of infectious syndromes caused by a variety of species of Candida, 6 of which cause most cases globally. Candidemia is probably the most commonly recognized syndrome associated with IC; however, Candida can cause invasive infection of any organ, especially visceral organs, vasculature, bones and joints, the eyes and central nervous system. Targeted prevention and empirical therapy are important interventions for patients at high risk for IC, and the current approach should be based on a combination of clinical risk factors and non-culture-based diagnostics, when available.

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

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.

Fungal Prosthetic Joint Infection Following Total Knee Arthroplasty: A Case Report

Introduction:

Prosthetic joint infection (PJI) is a rare complication of total knee replacement (TKR), yet it is a serious and debilitating condition. Bacterial infection accounts for the majority of cases and fungal infection is estimated to cause 1% of all prosthesis infection.

Case Report:

This case presents a 60years female, who presented to our outpatient orthopedic clinic complaining of right knee pain, swelling, and hotness. The physical examination revealed redness, hotness, restricted range of movement, and tibial loosening, 9 months following TKR revision. Culture of the joint aspirate showed growth of “Candida parapsilosis” and second aspirate confirmed the diagnosis. The patient then underwent two stages revision surgery with placement of amphotericin B loaded cement, to maintain high local antifungal concentration in addition to decrease the side effects of amphotericinB infusion such as thrombophlebitis and the more serious systemic effect as nephrotoxicity. The post-operative course was uneventful, with gradual improvement and restoration of normal movement range.

Conclusion:

Fungal PJI is a rare complication of TKR, yet it results in severe debilitating symptoms and impairment of the patient functional capacity. Careful evaluation of the patient followed by a detailed workup is necessary for the identification of the underlying causative micro-organism. Two-stage revision surgery with antifungal loaded cement spacer and antifungal therapy currently is the standard of management. To the best of our knowledge, this is the first fungal PJI following total knee arthroplasty reported in Jordan.

Breakthrough invasive fungal infections: Who is at risk?

The epidemiology of invasive fungal infections (IFIs) in immunocompromised individuals has changed over the last few decades, partially due to the increased use of antifungal agents to prevent IFIs. Although this strategy has resulted in an overall reduction in IFIs, a subset of patients develop breakthrough IFIs with substantial morbidity and mortality in this population. Here, we review the most significant risk factors for breakthrough IFIs in haematology patients, solid organ transplant recipients, and patients in the intensive care unit, focusing particularly on host factors, and highlight areas that require future investigation.

Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses

BACKGROUND

Fungal infections of inflatable penile prostheses (IPPs) are inadequately understood in the literature.

AIM

To review a multi-institution database of IPP infections to examine for common patient and surgical factors related to IPP fungal infections.

METHODS

This is a retrospective Institutional Review Board-approved analysis of 217 patients at 26 institutions who underwent salvage or device explant between 2001 and 2018. Patient data were compiled after an extensive record review.

OUTCOMES

26 patients (12%) with fungal infections were identified.

RESULTS

23 of 26 patients (83%) with a fungal IPP infection were either diabetic or overweight. 15 patients had undergone primary IPP implantation, and the other 11 had previously undergone an average of 1.7 IPP-related surgeries (range 1-3; median 2). The average age at implantation was 63 years (range 31-92; median 63). 18 of the 26 patients with fungal infection had diabetes (69%), with a mean hemoglobin A1c (HbA1c) value of 8.4 (range 5.8-13.3; median 7.5). Twenty-two patients (85%) were overweight or obese. The mean body mass index for all patients was 30.1 kg/m² (range 23.7-45 kg/m²; median 28.4 kg/m²), and that for diabetic patients was 30.8 kg/m² (range 24.1-45 kg/m², median 29.7 kg/m²). Ninety-one percent of implants were placed with intravenous antibiotics, consistent with current American Urological Association guidelines: an aminoglycoside plus first- or second-generation cephalosporin or vancomycin or ampicillin/sulbactam or piperacillin/tazobactam. 65% (17 of 26) of infected IPPs had only fungal growth in culture. No patient had concomitant immunosuppressive disease or recent antibiotic exposure before IPP implantation.

CLINICAL IMPLICATIONS

More than two-thirds of the fungal infections occurred in diabetic patients and 85% occurred in overweight or obese patients, suggesting that antifungal prophylaxis may be appropriate in these patients.

STRENGTHS & LIMITATIONS

This is the largest series of fungal infections reported to date in the penile prosthesis literature. The overall number of such cases, however, remains small.

CONCLUSION

Fungal infections represent 12% of all penile prosthesis infections in our series and were seen mostly in diabetic or overweight patients, who may benefit from antifungal prophylaxis. Gross MS, Reinstatler L, Henry GD, et al. Multicenter Investigation of Fungal Infections of Inflatable Penile Prostheses. J Sex Med 2019;16:1100-1105.

Defining breakthrough invasive fungal infection-Position paper of the mycoses study group education and research consortium and the European Confederation of Medical Mycology

Breakthrough invasive fungal infections (IFIs) have emerged as a significant problem in patients receiving systemic antifungals; however, consensus criteria for defining breakthrough IFI are missing. This position paper establishes broadly applicable definitions of breakthrough IFI for clinical research. Representatives of the Mycoses Study Group Education and Research Consortium (MSG-ERC) and the European Confederation of Medical Mycology (ECMM) reviewed the relevant English literature for definitions applied and published through 2018. A draft proposal for definitions was developed and circulated to all members of the two organisations for comment and suggestions. The authors addressed comments received and circulated the updated document for approval. Breakthrough IFI was defined as any IFI occurring during exposure to an antifungal drug, including fungi outside the spectrum of activity of an antifungal. The time of breakthrough IFI was defined as the first attributable clinical sign or symptom, mycological finding or radiological feature. The period defining breakthrough IFI depends on pharmacokinetic properties and extends at least until one dosing interval after drug discontinuation. Persistent IFI describes IFI that is unchanged/stable since treatment initiation with ongoing need for antifungal therapy. It is distinct from refractory IFI, defined as progression of disease and therefore similar to non-response to treatment. Relapsed IFI occurs after treatment and is caused by the same pathogen at the same site, although dissemination can occur. These proposed definitions are intended to support the design of future clinical trials and epidemiological research in clinical mycology, with the ultimate goal of increasing the comparability of clinical trial results.

Recurrent arthritis caused by Candida parapsilosis: a case report and literature review

BACKGROUND

Candida arthritis is extremely rare and also represents a major challenge of diagnosis and treatment. Here we reported a rare case of recurrent arthritis caused by Candida parapsilosis.

CASE PRESENTATION

A 56-year-old Chinese male suffered from recurrent pain and swelling in his right knee after several times of "small needle-knife" acupuncture and corticosteroid injection of the joint. Candida parapsilosis was cultured in his synovial fluid and identified by sequencing of its Internal Transcribed Spacer (ITS) gene. Here we present the radiological characteristics, arthroscopic pictures, and synovium pathology of this patient. Also, blood test and chemical analysis of his synovial fluid were listed as well as the ITS sequence of this Candida species identified. The patient underwent thorough arthroscopic debridement and then set on fluconazole 400 mg daily for 12 months. His symptoms resolved and no relapse was observed on the last follow-up. Additionally, a brief but comprehensive review of C. parapsilosis arthritis episodes from past to now were studied.

CONCLUSION

With the detailed clinical information reported in this case and our literature review, we hope they would add to our knowledge of C. parapsilosis arthritis - its clinical settings, laboratory features, radiological characteristics, arthroscopic findings and experience of management.

Candida glabrata-Induced Refractory Infectious Arthritis: A Case Report and Literature Review

The incidence of deep fungal infection due to non-albicans Candida species (especially Candida glabrata) has significantly increased in recent decades. Candida glabrata is an opportunistic pathogen of low virulence which mainly invades the gastrointestinal, genitourinary, and respiratory tracts, but has rarely been reported as complication of articular surgery in the literature. We present a case of knee fungal arthritis caused by C. glabrata after a minimally invasive arthroscopic surgery. In this case, the patient's knee got infected after arthroscopic treatment for a recurrent popliteal cyst, and she was unable to be cured by either debridement or antifungal drugs. Mycological and molecular identification of the necrotic tissues isolate revealed C. glabrata as etiologic agent. We originally planned to conduct a debridement once again, but it was found that the articular cartilage was extensively damaged during the operation. Besides, the magnetic resonance imaging of the affected knee also showed that the infection had invaded the subchondral bone. So we treated this case with a two-stage primary total knee arthroplasty with an antibiotic-laden cement spacer block. After a 10-month follow-up, the patient had completely recovered and has not experienced any recurrence to date. In addition, we review 21 cases of C. glabrata-induced infectious arthritis described to date in the literature.

The proper timing of second-stage revision in treating periprosthetic knee infection: reliable indicators and risk factors

Background

Two-stage revision is the standard procedure for periprosthetic knee infection. But when to perform the second-stage is still under debate. We attempt to search the reliable indicators, risk factors, and proper timing for the second-stage revision.

Methods

We reviewed and followed 81 infected total knee arthroplasty patients who underwent two-stage revision from January 2010 to January 2014. Our cohort included 56 males and 25 females, all patients were confirmed as PJI with the same phenotypic cultures. The average age was 64.8 ± 8.21 (range 36–78) months. The mean follow-up time was 46.5 ± 17.6 (range 12–72) months after the second-stage surgeries. The diagnostic parameters including serum C-reaction protein, erythrocyte sedimentation rate, and intraoperative frozen section at the time of re-implantation were analyzed. The spacer detention time and antibiotic treatment time were compared.

Results

Ten of them went through failed first- or second-stage surgeries. The overall success rate was 87.7%. The intraoperative frozen section is a good indicator at the time of re-implantation; the sensitivity and specificity is 90 and 83.1%. Serum CRP and ESR showed poor diagnostic value at time of re-implantation. Atypical pathogen infection, positive FS, and previous sinus were high-risk factors for failure of two-stage revision. Spacer detention time between 12 and 16 weeks had higher success rate than over 16 weeks.

Conclusion

The proper timing of re-implantation should be combined with disappearance of clinical symptoms and negative intraoperative FS with spacer detention time at 12 to 16 weeks.

Success Rate of Fungal Peri-Prosthetic Joint Infection Treated by 2-Stage Revision and Potential Risk Factors of Treatment Failure: A Retrospective Study

Background

The aim of this study was to investigate the success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and related factors of treatment failure to offer a better treatment protocol.

Material/Methods

We reviewed 18 joints (13 knees and 5 hips) of 17 patients (10 women and 7 men) diagnosed with fungal peri-prosthetic joint infection from January 2000 to June 2015 at our institute. The mean follow-up was 65.1 months (range, 25–129 months). All joints were treated with complete debridement, implantation of antifungal-loaded cement spacers, at least 6 weeks of parenteral antifungal agents, and delayed reimplantation.

Results

Notably, 15 joints were infected with Candida, and molds were isolated in 3 joints. The median duration of resection arthroplasty and reimplantation was 33.9 weeks (range, 12–132 weeks). Thirteen (10 knees and 3 hips, 72.2%) of the 18 joints (13 knees and 5 hips) had no recurrent or persistent infection, while the remaining 5 joints (3 knees and 2 hips, 27.8%) failed to control infection after reimplantation of prosthesis or spacer. The long interval between prosthesis resection and reimplantation (69 weeks vs. 23.1 weeks, p=0.240) and mixed bacterial infection (80% vs. 46.2%, p=0.314) were associated with higher failure rate.

Conclusions

Debridement with the retention of the prosthesis is not an ideal treatment protocol for fungal peri-prosthetic joint infection; thus, a two-stage revision could be valid. We suggest that 6 weeks of parenteral antifungal agents are necessary, and 6 subsequent weeks of oral antifungal treatment is also important. We do not recommend that the two-stage revision be performed on patients who have more than 2 host risk factors.

Efficacy of antifungal-impregnated cement spacer against chronic fungal periprosthetic joint infections after total knee arthroplasty

BACKGROUND

Although two-stage exchange arthroplasty is considered a treatment of choice for chronic features of fungal PJI (periprosthetic joint infection), there is no consensus for local use of antifungal agent. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer (AICS).

METHODS

Nine patients who were diagnosed and treated for chronic fungal PJI after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, AICS was inserted for all patients. Systemic antifungal medication was used during the interval between the two stage operations.

RESULTS

The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, five to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by open debridement tissue culture in three cases (33%). The average number of operations before final exchange arthroplasty was 2.7 times (range, one to five times). Average duration of antifungal agent use confirmed by sensitivity test was seven months (range, four to 15 months). Mean interval between the two stage operations was six months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months).

CONCLUSION

Two-stage exchange arthroplasty with AICS is a very effective strategy with excellent outcomes.

LEVEL OF EVIDENCE

Case series, IV.

Prosthetic Joint Infections Caused by Candida Species: A Systematic Review and a Case Series

The purpose of this study was to evaluate the efficacy of echinocandins in the treatment of Candida prosthetic joint infection (PJI) based on published literature and on patients we examined. A structured literature review of multiple databases was conducted to identify patients who received echinocandins for Candida PJIs. Additionally, we describe here the first cases of PJIs due to C. parapsilosis, successfully treated with prolonged anidulafungin therapy. Out of 17 patients, 12 were female and the mean age at diagnosis was 66.0 years. No risk factors associated with Candida PJIs were found in four patients (23.5%). Infection sites included the knee (n = 10, 62.5%), the hip (n = 6, 35.3%) and the shoulder (n = 1, 5.9%). The most frequently isolated Candida species were C. albicans (n = 7, 41.2%) and C. glabrata (n = 7, 41.2%), followed by C. parapsilosis (n = 2, 11.8%) and C. freyschussii (n = 1, 5.9%). All patients were cured with the combination of systemic antifungal therapy and surgical interventions. Two-stage exchange arthroplasty and resection arthroplasty were performed in five and nine patients, respectively. The most frequently used echinocandins were caspofungin (n = 11, 64.7%), followed by anidulafungin (n = 4, 23.5%) and micafungin (n = 2, 11.8%). The median duration (days) of echinocandin therapy was as follows: caspofungin (25.5, range 8-56), micafungin (14.0, range 4-56) and anidulafungin (58, range 14-90). This study supports the effective role of echinocandins, as well as the potential advantage of surgical intervention in the treatment of Candida PJIs. Furthermore, it provides fundamental data on the safety of long-term echinocandin therapy.

Candida Prosthetic Joint Infection. A Review of Treatment Methods

Fungal microorganisms are still a rare cause of bone and joint infections. We report a new case of knee prosthetic joint infection due to Candida albicans in a patient with a previous two-stage right knee arthroplasty for septic arthritis due to S. epidermidis occurred several months ago. Moreover, the treatment in 76 cases of Candida prosthetic joint infection has been discussed. Forty patients were female and mean age at diagnosis was 65.7 (± SD 18) yrs. No risk factors for candidal infection were found in 25 patients. Infection site was the knee in 38 patients and hip in 36; pain was present in 44 patients and swelling in 24. The most frequent species was C. albicans, followed by C. parapsilosis. Eleven patients were only treated with antifungal drugs being the outcome favourable in all of them. Two-stage exchange arthroplasty was performed in 30 patients, and resection arthroplasty in other 30; in three patients one-stage exchange arthroplasty was done. A favourable outcome was found in 58 patients after antifungal plus surgical treatment, in 11 after antifungal treatment alone and in one after surgery alone. The type of treatment is still not clearly defined and an algorithm for treatment in fungal PJI should be established, but various types of surgical procedures may be applied.