Candidal periprosthetic joint infection after primary total knee arthroplasty combined with ipsilateral intertrochanteric fracture: A case report

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.

Candida periprosthetic infection of the knee: a systematic review of surgical treatments and clinical outcomes

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.