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Gonzalez MR, Clunk MJ, Acosta JI, Bedi ADS, Karczewski D, Lozano-Calderón SA. High Rates of Treatment Failure and Amputation in Modular Endoprosthesis Prosthetic Joint Infections Caused by Fungal Infections With Candida. Clin Orthop Relat Res 2024; 482:1232-1242. [PMID: 37988003 PMCID: PMC11219170 DOI: 10.1097/corr.0000000000002918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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/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.
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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-Calderón
- Musculoskeletal Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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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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Li M, Fan M, Zhang Y, Xiao J, Liu T, Yu Q. Efficacy of DAIR in managing Candida parapsilosis-infected total knee arthroplasty with five-year follow-up: A case report and review of literature. Medicine (Baltimore) 2023; 102:e36246. [PMID: 38013258 PMCID: PMC10681585 DOI: 10.1097/md.0000000000036246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONALE Fungal periprosthetic joint infections (fPJIs) are relatively uncommon, accounting for approximately 1% of all PJIs. Revision surgery is typically recommended for fungal infections; however, the physical and financial impact on patients is significant. In this report, we present a case of fPJI successfully treated with debridement, antibiotics, and implant retention (DAIR) with a favorable outcome over a 5-year period. PATIENT CONCERN A 56-year-old male patient presented with a non-healing surgical incision 1 week after undergoing primary total knee arthroplasty on the right side. DIAGNOSIS Microbiological culture of the wound effusion identified Candida parapsilosis. Postoperatively, the patient exhibited a significant decrease in serum albumin levels and poor glycemic control. Both C-reactive protein and erythrocyte sedimentation rate were elevated. INTERVENTIONS A comprehensive DAIR procedure was performed, along with continuous closed irrigation using fluconazole for 1 week. The patient received intravenous voriconazole for 4 weeks, followed by oral fluconazole for an additional 3 months. OUTCOMES At 1- and 5-year follow-up appointments, the patient C-reactive protein and erythrocyte sedimentation rate levels were within normal limits, and there was no evidence of swelling, erythema, or tenderness in the right knee joint, indicating no signs of infection. LESSONS DAIR is an effective treatment for early fPJIs, and continuous closed irrigation may provide specific advantages. The patient nutritional status plays a crucial role in the management of periprosthetic infections.
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Affiliation(s)
- Menglong Li
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Mingrui Fan
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yuchen Zhang
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jianlin Xiao
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Tong Liu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Qingwei Yu
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
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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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Tummala SV, Lin E, Mujahed T, Beauchamp CP, Blair JE, Goulding KA. Rare Bipolaris Species Fungal Periprosthetic Hip Infection in an Immunocompetent Host: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00018. [PMID: 37889989 DOI: 10.2106/jbjs.cc.23.00348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
CASE We present a case report of a 64-year-old man who developed a rare Bipolaris species fungal periprosthetic joint infection (PJI) after revision arthroplasty for complications associated with a metal-on-metal total hip arthroplasty. The patient underwent a 2-stage debridement with antibiotic bead placement and implant retention, along with chronic antifungal suppression. At the 2-year follow-up, the patient remained asymptomatic. CONCLUSION Fungal PJI with filamentous fungi such as Bipolaris species is a rare clinical entity. This case report highlights the clinical presentation and management of this rare condition.
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Affiliation(s)
- Sailesh V Tummala
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Eugenia Lin
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Tala Mujahed
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Janis E Blair
- Department of Infectious Diseases, Mayo Clinic Arizona, Phoenix, Arizona
| | - Krista A Goulding
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
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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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Zhang C, Lin Y, Huang C, Huang Z, Fang X, Bai G, Zhang Z, Li W, Zhang W. Metagenomic next-generation sequencing assists the diagnosis treatment of fungal osteoarticular infections. Front Cell Infect Microbiol 2022; 12:1072539. [PMID: 36506031 PMCID: PMC9726756 DOI: 10.3389/fcimb.2022.1072539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/03/2022] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Chaofan Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yunzhi Lin
- Department of Stomatology, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Stomatology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changyu Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zida Huang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinyu Fang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guochang Bai
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zeyu Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenbo Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenming Zhang
- Department of Orthopaedic Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Department of Orthopaedic Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,Fujian Provincial Institute of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,*Correspondence: Wenming Zhang,
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Williams BT, Hogan C, Damioli L. Two-Stage Revision Total Knee Arthroplasty for Chronic Histoplasma Capsulatum Prosthetic Joint Infection: A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00040. [PMID: 36075022 DOI: 10.2106/jbjs.cc.22.00155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
CASE This report describes a histoplasma capsulatum total knee prosthetic joint infection (PJI) in an immunosuppressed patient treated with a 2-stage revision. The diagnosis of PJI was made based on minor criteria, and the causative organism was identified from cultures obtained at the time of explantation. The patient underwent induction with amphotericin B, followed by oral antifungal therapy and a successful 2-stage revision with a hinged prosthesis with an interval of ∼7 months between stage 1 and stage 2. At the most recent follow-up (18 months), she remained clear from infection with planned lifetime antifungal suppression. CONCLUSION This case report highlights the importance of consideration of atypical organisms when treating immunocompromised patients. Furthermore, this case report documents one of the few cases of histoplasma PJI and provides a successful treatment algorithm to potentially be applied to future cases.
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Affiliation(s)
- Brady T Williams
- University of Colorado, Department of Orthopaedics; Aurora, Colorado
| | - Craig Hogan
- University of Colorado, Department of Orthopaedics; Aurora, Colorado
| | - Laura Damioli
- University of Colorado, Division of Infectious Diseases, Subdivision of Orthopedic Infectious Diseases; Aurora, Colorado
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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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The Identification of Multidrug-Resistant Microorganisms including Bergeyella zoohelcum Acquired from the Skin/Prosthetic Interface of Amputees and Their Susceptibility to Medihoney™ and Garlic Extract (Allicin). Microorganisms 2022; 10:microorganisms10020299. [PMID: 35208754 PMCID: PMC8874569 DOI: 10.3390/microorganisms10020299] [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: 11/09/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 02/01/2023] Open
Abstract
Users of prosthetic devices face the accumulation of potentially drug-resistant pathogenic bacteria on the skin/prosthesis interface. In this study, we took surface swabs of the skin/prosthesis interface of eleven disabled athletes to identify microorganisms present. In addition to determining their antimicrobial resistance profile, we assessed their sensitivity to Manuka honey and Garlic extract (allicin). Eleven volunteers were directed to swab the skin at the skin/prosthesis interface. After initial isolation of microorganisms, we employed the following general microbiological methods: Gram stain, Catalase test, Oxidase test, lactose fermenting capability, haemolytic capability, Staphaurex, mannitol fermenting capability, Streptex; API Staph, 20E, Candida, and BBL crystal identification system tests. Once identified, isolates were analysed for their sensitivity to penicillin, erythromycin, ampicillin, vancomycin, ceftazidime, ciprofloxacin, gentamicin, and colistin-sulphate. Isolates were also analysed for their sensitivity to allicin (Garlic Extract (GE)) and Manuka honey (Medihoney™) (MH). Eleven isolates were identified: Bacillus cereus, Staphylococcus haemolyticus, Staphylococcus aureus, Micrococcus luteus, Pseudomonas oryzihabitans, Micrococcus spp., Bacillus subtilis, Group D Streptococcus, Pantoea spp., Enterobacter cloacae, and Bergeyella zoohelcum. All isolates were resistant to 1 unit of penicillin and 10 μg of ampicillin. Bergeyella zoohelcum was observed to have the widest range of resistance with observed resistance against five of the eight antimicrobials employed in this study. This study highlights the prevalence of uncommon drug-resistant microorganisms on the skin within a vulnerable population, highlighting the potential for MH or GE intervention.
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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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12
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Koutserimpas C, Chamakioti I, Zervakis S, Raptis K, Alpantaki K, Kofteridis DP, Vrioni G, Samonis G. Non- Candida Fungal Prosthetic Joint Infections. Diagnostics (Basel) 2021; 11:diagnostics11081410. [PMID: 34441344 PMCID: PMC8391504 DOI: 10.3390/diagnostics11081410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Fungal prosthetic joint infections (PJIs) are rare, especially those caused by non-Candida species. Treatment has not been fully elucidated, since a plethora of antifungal and surgical interventions have been proposed. Τhis study represents an effort to clarify the optimal management of non-Candida fungal PJIs, by reviewing all relevant published cases. Methods: A thorough review of all existing non-Candida fungal PJIs in the literature was conducted. Data regarding demographics, responsible organisms, antifungal treatment (AFT), surgical intervention, time between initial arthroplasty and onset of symptoms, and time between onset of symptoms and firm diagnosis, as well as the infection’s outcome, were evaluated. Results: Forty-two PJIs, in patients with mean age of 66.2 years, were found and reviewed. Aspergillus spp. were isolated in most cases (10; 23.8%), followed by Coccidioides spp. (7; 16.7%) and Pichiaanomala (5; 11.9%). Fluconazole was the preferred antifungal regimen (20 cases; 47.6%), followed by amphotericin B (18 cases; 42.9%), while the mean AFT duration was 9.4 months (SD = 7.06). Two-stage revision arthroplasty (TSRA) was performed in 22 cases (52.4%), with the mean time between stages being 5.2 months (SD = 2.9). The mean time between initial joint implantation and onset of symptoms was 42.1 months (SD = 50.7), while the mean time between onset of symptoms and diagnosis was 5.8 months (SD = 14.3). Conclusions: Non-Candida fungal PJIs pose a clinical challenge, demanding a multidisciplinary approach. The present review has shown that combination of TSRA separated by a 3–6-month interval and prolonged AFT has been the standard of care in the studied cases.
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Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Ifigeneia Chamakioti
- Emergency Department, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Stylianos Zervakis
- Department of Cardiology, University Hospital of Heraklion, 714 09 Heraklion, Greece
| | - Konstantinos Raptis
- Department of Orthopaedics and Traumatology, "251" Hellenic Air Force General Hospital of Athens, 115 25 Athens, Greece
| | - Kalliopi Alpantaki
- Department of Orthopaedics and Traumatology, "Venizeleion" General Hospital of Heraklion, 714 09 Heraklion, Greece
| | - Diamantis P Kofteridis
- Department of Internal Medicine, University Hospital of Heraklion, 715 00 Heraklion, Greece
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27 Athens, Greece
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, 715 00 Heraklion, Greece
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13
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Hu L, Fu J, Zhou Y, Chai W, Zhang G, Hao L, Chen J. Trends in microbiological profiles and antibiotic resistance in periprosthetic joint infections. J Int Med Res 2021; 49:3000605211002784. [PMID: 33787371 PMCID: PMC8020254 DOI: 10.1177/03000605211002784] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective This study examined the trends in demographics, the distribution of
microorganisms, and antibiotic resistance in patients with periprosthetic
joint infection (PJI). Methods We conducted a retrospective study of 231 consecutive patients diagnosed with
PJI in our hospital from January 2006 to December 2015 (93 and 138 patients
diagnosed in 2006–2010 and 2011–2015, respectively). The linear-by-linear
chi-squared test was used to assess the trends in demographics, the
distribution of microorganisms, and antibiotic resistance. Results Gram-positive cocci accounted for 63.9% of all pathogens, and
coagulase-negative Staphylococcus (CoNS) accounted for
38.1% of all isolates. The proportion of isolates identified as
methicillin-resistant CoNS significantly increased over the study period
(39.0% vs. 61.8%). In addition, the proportions of levofloxacin-resistant
CoNS (4.9% vs. 21.8%) and Staphylococcus aureus (6.3% vs.
45.0%) isolates significantly increased over the study period. By contrast,
the proportions of penicillin-resistant CoNS (82.9% vs. 40.0%) and
S. aureus (75.0% vs. 30.0%) isolates decreased over the
study period. Conclusion Our research revealed changes in the distribution of microorganisms and
antibiotic resistance profile of the pathogens responsible for PJI over
time, which could complicate treatment. These findings may serve as a
reference for strategies to prevent and empirically treat PJI in China.
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Affiliation(s)
- Lifeng Hu
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The Fifth Central Hospital of Tianjin, Tianjin, China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yonggang Zhou
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Wei Chai
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guoqiang Zhang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Libo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jiying Chen
- Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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14
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Babu S, Vaishya R, Butta H, Sardana R, Mehndiratta L, Gulati Y, Kharbanda Y, Tandon H. A retrospective analysis of the prosthetic joint infections of the hip and knee at a tertiary care center of India. APOLLO MEDICINE 2021. [DOI: 10.4103/am.am_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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15
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Shah S, Haq S, Antony SJ. Coccidiomycosis immitis Resulting in a Prosthetic Joint Infection in an Immunocompetent Patient after a Total Hip Arthroplasty: A Case Report and Review of the Literature. Infect Disord Drug Targets 2020; 22:e170322188282. [PMID: 33231149 DOI: 10.2174/1871526520999201123205249] [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: 07/01/2020] [Revised: 10/06/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022]
Abstract
Coccidiomycosis immitis is a fungal infection that is a rare cause of prosthetic joint infection (PJI) in patients. This case report describes an immunocompetent patient who had a right total hip arthroplasty (THA) complicated with Coccidiomycosis immitis. This patient is the 9th reported case of Coccidiomycosis immitis causing a PJI and only the second case to be reported in a THA. Once progressed, it can be difficult to treat, often reoccurring and requiring repeat sur-gical and prolonged therapy. We discuss the clinical presentation in this patient and review the literature on the current pub-lished cases.
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Affiliation(s)
- Sidra Shah
- Department of Medicine, Section of Infectious Disease, Burrell College of Osteopathic Medicine, Las Cruces, New Mexico,. United States
| | - Syed Haq
- Department of Medicine, Section of Infectious Disease, Burrell College of Osteopathic Medicine, Las Cruces, New Mexico,. United States
| | - Suresh J Antony
- Texas Tech University Health Sciences Center, El Paso, Texas,. United States
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16
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Riaz T, Tande AJ, Steed LL, Demos HA, Salgado CD, Osmon DR, Marculescu CE. Risk Factors for Fungal Prosthetic Joint Infection. J Bone Jt Infect 2020; 5:76-81. [PMID: 32454521 PMCID: PMC7242408 DOI: 10.7150/jbji.40402] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Fungal prosthetic joint infections (PJIs) are rare and often associated with poor outcome; however, risk factors are not well described. Methods: This was a retrospective case control study among all patients with PJIs from 2006-2016 at two major academic centers. Each fungal PJI case was matched 1:1 with a bacterial PJI control by joint (hip, knee, shoulder) and year of diagnosis. We compared demographics, comorbidities, and clinical characteristics between cases and controls using chi square/Fisher's exact or Wilcoxon rank sum test. Independent risk factors were identified with multivariable logistic regression. Results: Forty-one fungal PJIs occurred over the study and 61% were due to Candida albicans. The hip was involved in 51.2% of cases, followed by the knee (46.3%). Compared to bacterial PJI, fungal PJI cases were more likely to have received antibiotics within the previous 3 months (70.7% vs 34%, P=.001), wound drainage lasting >5 days (48% vs 9%, P=.0002), had a lower median CRP (2.95 mg/dl vs 5.99, P=.013) and synovial fluid white blood cell count (13,953 cells/mm3 vs 33,198, P=.007), and a higher proportion of prior two-stage exchanges (82.9% vs 53.6%, P=.008). After controlling for center, prolonged wound drainage (OR, 7.3; 95% CI, 2.02-26.95) and recent antibiotics (OR, 3.4; 95% CI, 1.2-9.3) were significantly associated with fungal PJI. Conclusion: In our study, Candida albicans was the most common species in fungal PJIs and prolonged wound drainage and recent antibiotics were independent risk factors. These clinical characteristics may help providers anticipate fungal PJI and adjust management strategies.
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Affiliation(s)
- Talha Riaz
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Aaron J. Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Lisa L. Steed
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina
| | - Harry A. Demos
- Department of Orthopaedics and Rehabilitation, Medical University of Charleston, Charleston, South Carolina
| | - Cassandra D. Salgado
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina
| | - Douglas R. Osmon
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Camelia E. Marculescu
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, South Carolina
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17
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Abstract
Fungal periprosthetic joint infection (PJI) is a devastating complication because it can be difficult to diagnose, manage, and eradicate. Fungal PJI treatment requires a systematic approach. Increased awareness is essential when patients with painful arthroplasties present with immunosuppression, significant comorbidities, multiple surgeries, and history of drug use. Every suspected fungal PJI should be promptly diagnosed using readily available serum and synovial fluid markers. Surgical management involves débridement, antibiotics, and implant retention, one-stage exchange arthroplasty, prosthetic articulating spacers, and two-stage exchange arthroplasty. Because mycotic infections develop robust biofilms, the utility of débridement, antibiotics, and implant retention and one-stage revisions seem limited. A thorough irrigation and débridement is essential to decrease infection burden. Adjunctive local and systemic antifungal therapy is critical, although the agent choice and duration should be tailored appropriately. Future high-quality studies are needed to develop standardized guidelines for the management of fungal PJI.
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18
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Fusini F, Aprato A, Massè A, Bistolfi A, Girardo M, Artiaco S. Candida periprosthetic infection of the hip: a systematic review of surgical treatments and clinical outcomes. INTERNATIONAL ORTHOPAEDICS 2019; 44:15-22. [DOI: 10.1007/s00264-019-04369-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
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19
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Koutserimpas C, Zervakis SG, Maraki S, Alpantaki K, Ioannidis A, Kofteridis DP, Samonis G. Non- albicans Candida prosthetic joint infections: A systematic review of treatment. World J Clin Cases 2019; 7:1430-1443. [PMID: 31363471 PMCID: PMC6656666 DOI: 10.12998/wjcc.v7.i12.1430] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/16/2019] [Accepted: 04/19/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Non-albicans Candida prosthetic joint infections (PJIs) are rare. Optimal treatment involves a two-stage revision surgery in combination with an antifungal agent. However, no clear guidelines have been developed regarding the agent or treatment duration. Hence, a broad range of antifungal and surgical treatments have been reported so far.
AIM To clarify treatment of non-albicans Candida PJIs.
METHODS A literature review of all existing non-albicans Candida PJIs cases through April 2018 was conducted. Information was extracted about demographics, comorbidities, responsible species, duration and type of antifungal treatment, type of surgical treatment, time between initial arthroplasty and symptom onset, time between symptom onset and definite diagnosis, outcome of the infection and follow-up.
RESULTS A total of 83 cases, with a mean age of 66.3 years, were located. The causative yeast isolated in most cases was C. parapsilosis (45 cases; 54.2%), followed by C. glabrata (18 cases; 21.7%). The mean Charlson comorbidity index was 4.4 ± 1.5. The mean time from arthropalsty to symptom onset was 27.2 ± 43 mo, while the mean time from symptom onset to culture-confirmed diagnosis was 7.5 ± 12.5 mo. A two stage revision arthroplasty (TSRA), when compared to one stage revision arthroplasty, had a higher success rate (96% vs 73%, P = 0.023). Fluconazole was the preferred antifungal agent (59; 71%), followed by amphotericin B (41; 49.4%).
CONCLUSION The combination of TSRA and administration of prolonged antifungal therapy after initial resection arthroplasty is suggested on the basis of limited data.
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Affiliation(s)
- Christos Koutserimpas
- Department of Orthopaedics and Traumatology, “251” Hellenic Air Force General Hospital of Athens, Athens 11525, Greece
| | - Stylianos G Zervakis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Heraklion 71110, Greece
| | - Sofia Maraki
- Department of Clinical Microbiology and Microbial Pathogenesis, University Hospital of Heraklion, Crete, Heraklion 71110, Greece
| | - Kalliopi Alpantaki
- Department of Materials Science and Technology, University of Crete, Heraklion, Heraklion 71110, Greece
| | - Argyrios Ioannidis
- Department of General Surgery, “Sismanoglion” General Hospital of Athens, Athens 15126, Greece
| | - Diamantis P Kofteridis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Heraklion 71110, Greece
| | - George Samonis
- Department of Internal Medicine, University Hospital of Heraklion, Crete, Heraklion 71110, Greece
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20
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Sidhu MS, Cooper G, Jenkins N, Jeys L, Parry M, Stevenson JD. Prosthetic fungal infections: poor prognosis with bacterial co-infection. Bone Joint J 2019; 101-B:582-588. [PMID: 31039037 DOI: 10.1302/0301-620x.101b5.bjj-2018-1202.r1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management. PATIENTS AND METHODS A total of 1189 patients with a PJI were managed in our bone infection service between 2006 and 2015; 22 (1.85%) with co-infective bacterial and fungal PJI were included in the study. There were nine women and 13 men, with a mean age at the time of diagnosis of 64.5 years (47 to 83). Their mean BMI was 30.9 kg/m2 (24 to 42). We retrospectively reviewed the outcomes of these PJIs, after eight total hip arthroplasties and 14 total knee arthroplasties. The mean clinical follow-up was 4.1 years (1.4 to 8.8). RESULTS The median number of risk factors for PJI was 5.5 (interquartile range (IQR) 3.25 to 7.25). All seven patients who initially underwent debridement and implant retention (DAIR) had a recurrent infection that led to a staged revision. All 22 patients underwent the first of a two-stage revision. None of the nine patients with negative tissue cultures at the second stage had a recurrent infection. The rate of recurrent infection was significantly higher in the presence of multidrug-resistant bacteria (p = 0.007), a higher C-reactive protein (CRP) at the time of presentation (p = 0.032), and a higher number of co-infective bacterial organisms (p = 0.041). The overall rate of eradication of infection after two and five years was 50% (95% confidence interval (CI) 32.9 to 75.9) and 38.9% (95% CI 22.6 to 67), respectively. CONCLUSION The risk of failure to eradicate infection with the requirement of amputation associated with this diagnosis is much higher than in patients with PJI without bacterial and fungal co-infection, and this risk is heightened when the fungal organism is joined by polymicrobial and multidrug-resistant bacterial organisms. Cite this article: Bone Joint J 2019;101-B:582-588.
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Affiliation(s)
- M S Sidhu
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK
| | - G Cooper
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK
| | - N Jenkins
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK.,Department of Infection and Tropical Medicine, University Hospitals Birmingham, Birmingham, UK
| | - L Jeys
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK.,School of Life and Health Sciences, Aston University, Birmingham, UK
| | - M Parry
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
| | - J D Stevenson
- Bone Infection Service, Royal Orthopaedic Hospital, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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21
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Boyle KK, Kuo FC, Horcajada JP, Hughes H, Cavagnaro L, Marculescu C, McLaren A, Nodzo SR, Riccio G, Sendi P, Silibovsky R, Stammers J, Tan TL, Wimmer M. General Assembly, Treatment, Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S225-S237. [PMID: 30360976 DOI: 10.1016/j.arth.2018.09.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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22
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Belden K, Cao L, Chen J, Deng T, Fu J, Guan H, Jia C, Kong X, Kuo FC, Li R, Repetto I, Riccio G, Tarabichi M. Hip and Knee Section, Fungal Periprosthetic Joint Infection, Diagnosis and Treatment: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S387-S391. [PMID: 30343967 DOI: 10.1016/j.arth.2018.09.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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23
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Kim JK, Lee DY, Kang DW, Ro DH, Lee MC, Han HS. Efficacy of antifungal-impregnated cement spacer against chronic fungal periprosthetic joint infections after total knee arthroplasty. Knee 2018; 25:631-637. [PMID: 29778657 DOI: 10.1016/j.knee.2018.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/25/2018] [Accepted: 04/13/2018] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jong-Keun Kim
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Do-Yoon Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Wan Kang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Du-Hyun Ro
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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24
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Lee YR, Kim HJ, Lee EJ, Sohn JW, Kim MJ, Yoon YK. Prosthetic Joint Infections Caused by Candida Species: A Systematic Review and a Case Series. Mycopathologia 2018; 184:23-33. [PMID: 30051279 DOI: 10.1007/s11046-018-0286-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Yoo Ra Lee
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyun Jung Kim
- Institute for Evidence-Based Medicine, Cochrane Korea, Seoul, Republic of Korea.,Department of Preventive Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eun Ju Lee
- Medical Library, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jang Wook Sohn
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ja Kim
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea.
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25
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Single-Stage Revision for Chronic Fungal Periprosthetic Joint Infection: An Average of 5 Years of Follow-Up. J Arthroplasty 2017; 32:2523-2530. [PMID: 28478188 DOI: 10.1016/j.arth.2017.03.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/25/2017] [Accepted: 03/13/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Periprosthetic infections caused by fungal pathogens are a rare entity, and there exist no definite guidelines according to which these infections can be successfully managed. In these situations, we wondered whether patients could be treated successfully for their fungal infections with single-stage revision. METHODS A retrospective analysis between January 2004 and October 2014 included 11 patients (4 hips and 7 knees) with chronic fungal periprosthetic joint infection who underwent single-stage revision, including aggressive soft-tissue debridement, thorough removal of infected components and cement, pouring powdered vancomycin into the medullary cavity and direct intra-articular injection of fungus-sensitive antibiotics, and a reasonable combination of antifungal agents and antibacterial medications. Recurrence of infection and clinical outcomes were evaluated. The average follow-up was 5 years (range, 2-10 years). RESULTS There were 3 failures during the study period; 1 patient died during the perioperative period because of acute heart failure on the eighth postoperative day. Of the 11 patients, 7 patients had satisfactory outcomes and required no additional surgical or medical treatment for recurrence of infection. The mean postoperative Harris hip score and Hospital for Special Surgery knee score was 77 points (67-88 points; P < .05) and 78 points (73-84 points; P < .05), respectively, at the most recent assessment. CONCLUSION Treatment of chronic fungal periprosthetic joint infection with single-stage revision can be fairly effective for achieving acceptable functional outcomes, which indicated that this may be a feasible alternative strategy in selected patients.
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