Candida Prosthetic Joint Infection. A Review of Treatment Methods

Progress in Designing Therapeutic Antimicrobial Hydrogels Targeting Implant-associated Infections: Paving the Way for a Sustainable Platform Applied to Biomedical Devices

Implantable biomedical devices have found widespread use in restoring lost functions or structures within the human body, but they face a significant challenge from microbial-related infections, which often lead to implant failure. In this context, antimicrobial hydrogels emerge as a promising strategy for treating implant-associated infections owing to their tunable physicochemical properties. However, the literature lacks a comprehensive analysis of antimicrobial hydrogels, encompassing their development, mechanisms, and effect on implant-associated infections, mainly in light of existing in vitro, in vivo, and clinical evidence. Thus, this review addresses the strategies employed by existing studies to tailor hydrogel properties to meet the specific needs of each application. Furthermore, this comprehensive review critically appraises the development of antimicrobial hydrogels, with a particular focus on solving infections related to metallic orthopedic or dental implants. Then, preclinical and clinical studies centering on providing quantitative microbiological results associated with the application of antimicrobial hydrogels are systematically summarized. Overall, antimicrobial hydrogels benefit from the tunable properties of polymers and hold promise as an effective strategy for the local treatment of implant-associated infections. However, future clinical investigations, grounded on robust evidence from in vitro and preclinical studies, are required to explore and validate new antimicrobial hydrogels for clinical use.

Prosthetic Joint Infections due to Candida Species: A Multicenter International Study

BACKGROUND

Prosthetic joint infection (PJI) caused by Candida spp is a severe complication of arthroplasty. We investigated the outcomes of Candida PJI.

METHODS

This was a retrospective observational multinational study including patients diagnosed with Candida-related PJI between 2010 and 2021. Treatment outcome was assessed at 2-year follow-up.

RESULTS

A total of 269 patients were analyzed. Median age was 73.0 (interquartile range [IQR], 64.0-79.0) years; 46.5% of patients were male and 10.8% were immunosuppressed. Main infection sites were hip (53.0%) and knee (43.1%), and 33.8% patients had fistulas. Surgical procedures included debridement, antibiotics, and implant retention (DAIR) (35.7%), 1-stage exchange (28.3%), and 2-stage exchange (29.0%). Candida spp identified were Candida albicans (55.8%), Candida parapsilosis (29.4%), Candida glabrata (7.8%), and Candida tropicalis (5.6%). Coinfection with bacteria was found in 51.3% of cases. The primary antifungal agents prescribed were azoles (75.8%) and echinocandins (30.9%), administered for a median of 92.0 (IQR, 54.5-181.3) days. Cure was observed in 156 of 269 (58.0%) cases. Treatment failure was associated with age >70 years (OR, 1.811 [95% confidence interval {CI}: 1.079-3.072]), and the use of DAIR (OR, 1.946 [95% CI: 1.157-3.285]). Candida parapsilosis infection was associated with better outcome (OR, 0.546 [95% CI: .305-.958]). Cure rates were significantly different between DAIR versus 1-stage exchange (46.9% vs 67.1%, P = .008) and DAIR versus 2-stage exchange (46.9% vs 69.2%, P = .003), but there was no difference comparing 1- to 2-stage exchanges (P = .777).

CONCLUSIONS

Candida PJI prognosis seems poor, with high rate of failure, which does not appear to be linked to immunosuppression, use of azoles, or treatment duration.

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.

Is Silver Addition to Scaffolds Based on Polycaprolactone Blended with Calcium Phosphates Able to Inhibit Candida albicans and Candida auris Adhesion and Biofilm Formation?

Candida spp. periprosthetic joint infections are rare but difficult-to-treat events, with a slow onset, unspecific symptoms or signs, and a significant relapse risk. Treatment with antifungals meets with little success, whereas prosthesis removal improves the outcome. In fact, Candida spp. adhere to orthopedic devices and grow forming biofilms that contribute to the persistence of this infection and relapse, and there is insufficient evidence that the use of antifungals has additional benefits for anti-biofilm activity. To date, studies on the direct antifungal activity of silver against Candida spp. are still scanty. Additionally, polycaprolactone (PCL), either pure or blended with calcium phosphate, could be a good candidate for the design of 3D scaffolds as engineered bone graft substitutes. Thus, the present research aimed to assess the antifungal and anti-biofilm activity of PCL-based constructs by the addition of antimicrobials, for instance, silver, against C. albicans and C. auris. The appearance of an inhibition halo around silver-functionalized PCL scaffolds for both C. albicans and C. auris was revealed, and a significant decrease in both adherent and planktonic yeasts further demonstrated the release of Ag+ from the 3D constructs. Due to the combined antifungal, osteoproliferative, and biodegradable properties, PCL-based 3D scaffolds enriched with silver showed good potential for bone tissue engineering and offer a promising strategy as an ideal anti-adhesive and anti-biofilm tool for the reduction in prosthetic joints of infections caused by Candida spp. by using antimicrobial molecule-targeted delivery.

Novel Local Antifungal Treatment for Fungal Periprosthetic Joint Infection With Continuous Local Antibiotic Perfusion: A Surgical Technique

Fungal periprosthetic joint infections are one of the most intractable orthopedic disorders. Continuous local antibiotic perfusion allows direct administration of the antifungal agent micafungin into the local infection area at biofilm-disruptive concentrations, while controlling the dead space in addition to conventional treatment. Although the appropriate use of continuous local antibiotic perfusion requires familiarity with the characteristics of local antibiotic perfusion, it is a versatile treatment modality that can improve the clinical outcomes of fungal periprosthetic joint infection in combination with conventional treatment methods.

Efficacy of DAIR in managing Candida parapsilosis-infected total knee arthroplasty with five-year follow-up: A case report and review of literature

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.

Candida Colonization on the Surface of Contact Lenses in Long-Term Wearers and Boston Type 1 Keratoprosthesis Patients Presenting as White Mulberry-Shaped Deposits

PURPOSE

To report Candida colonies on the surface of the contact lens in long-term contact lens wearers and patients with Boston type 1 keratoprosthesis (KPro I).

METHODS

A retrospective study was performed based on analyzing cultures from bandage contact lenses with small whitish mulberry-shaped deposits on their surface.

RESULTS

Eight samples (from seven patients) were positive for Candida. Seven of the eight were positive for Candida parapsilosis.

CONCLUSIONS

The whitish deposits on contact lenses are often Candida colonies that colonize the surface but do not cause an active infection in the eye. C. parapsilosis is well-known for colonizing prosthetic devices. We underline the importance of including Candida species in the differential diagnosis of lens deposits, especially in susceptible patients such as keratoprosthesis carriers.

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.

Use of Fluconazole-impregnated Beads to Treat Osteomyelitis Caused by Coccidioides in a Pigtailed Macaque (Macaca nemestrina)

A 3-y-old male pigtailed macaque (Macaca nemestrina) presented for swelling of the left distal forearm and decreased use of the arm. The monkey had been raised at an indoor-outdoor facility in Arizona and transferred to an indoor facility in Washington 2 mo prior to presentation. A preliminary diagnosis of fungal osteomyelitis of the radius was made based on radiographs and Coccidioides titers. In addition to systemic antifungal treatment, surgery was performed to debride the bony lesion and implant polymethylmethacrylate beads impregnanted with the anti-fungal fluconazole. Histologic examination of the debrided material confirmed the diagnosis of fungal osteomyelitis. The surgical procedure resulted in clinical improvement, as evidenced by weight gain and decreased Coccidioides titers. The beads were removed in a second surgery, and the bony lesion completely resolved. With continued systemic fluconazole treatment, the monkey remained healthy with no further evidence of osteomyelitis. Coccidioides is an emerging pathogen that causes significant morbidity and mortality in both humans and animals. Bone infections can be resistant to systemic treatment, and the implantation of fluconazoleimpregnated beads may offer a successful treatment strategy for fungal osteomyelitis.

Fungal Prosthetic Joint Infection in Revised Knee Arthroplasty: An Orthopaedic Surgeon’s Nightmare

Fungal prosthetic joint infections (PJIs), despite the fact that they are rare, represent a devastating complication. Such infections in revised knee arthroplasties pose a unique surgical and medical challenge. A rare case of Candida parapsilosis PJI in revised knee arthroplasty is reported. Furthermore, a thorough review of all published fungal PJIs cases in revised knee arthroplasties is provided. A 72-year-old female with total knee replacement surgery due to osteoarthritis 10 years ago, followed by two revision surgeries six and two years ago due to aseptic loosening, presented with signs and symptoms of septic loosening of the knee components. Resection arthroplasty and cement-spacer placement was performed and periprosthetic tissue cultures yielded Candida parapsilosis. The patient was commenced on proper antifungal treatment (AFT) for six months and then the second stage of the revision surgery was performed successfully. From 2000 to 2022, a total of 46 patients with median age 69 years [interquartile range (IQR = 10)], suffering fungal PJI occurring in revised knee arthroplasty have been reported. The median time from initial arthroplasty to symptoms’ onset was 12 months (IQR = 14). Cultures of local material (52.2%) and histology (6.5%) were the reported diagnostic method, while Candida species were the most commonly isolated fungi. Regarding surgical management, two-stage revision arthroplasty (TSRA) was performed in most cases (54.3%), with median time-interval of six months (IQR = 6) between the two stages. Regarding AFT, fluconazole was the preferred antifungal compound (78.3%), followed by voriconazole and amphotericin B (19.6% each). The median duration of AFT was five months (IQR = 4.5). Infection’s outcome was successful in 38 cases (82.6%). Fungal PJIs, especially in revised knee arthroplasties, are devastating complications. A combination of AFT and TSRA seems to be the treatment of choice. TSRA in these cases poses a special challenge, since major bone defects may be present. Therapeutic procedures remain unclear, thus additional research is needed.

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.

Physicochemical Characterization of Europium-Doped Hydroxyapatite Thin Films with Antifungal Activity

Owing to its unique biological and physicochemical properties, hydroxyapatite (HAp) represents one of the most extensively studied biomaterials for biomedical applications. It is well known that Candida is currently one of the fungi frequently involved in the onset and development of post-implant infections and, owing to the appearance of antifungal resistance, it is quite difficult to treat despite all the tremendous efforts made in this regard by the scientific world. Therefore, in this context, we report for the first time in this paper, the development and characterization of europium-doped thin films (5EuHAp, xEu = 0.05) on a Si substrate by a spin-coating method. The results of ultrasound (US), zeta (ζ) potential, X-ray diffraction (XRD), X-ray photoelectron spectroscopy (XPS), transmission electron microscopy (TEM), scanning electron microscopy (SEM), and Fourier-transform infrared spectroscopy (FTIR) studies are presented. The XRD studies conducted on 5EuHAp suspension revealed the nanometric dimensions of the particles and sample purity. In addition, a moderate stability of the 5EuHAp suspension was observed. XPS measurements revealed the presence of Eu 3d in the 5EuHAp thin films. In the SEM micrographs, the surface uniformity and the absence of the surface defects could be observed. Moreover, the results of the FTIR studies showed the presence of the vibrational bands specific to the HAp structure in the studied sample. The antifungal activity of the HAp and 5EuHAp suspensions and coatings was evaluated using the Candida albicans ATCC 10231 (C. albicans) fungal strain. The qualitative assays of the antifungal properties of HAp and 5EuHAp coatings were also visualized by SEM and CLSM. The antifungal studies revealed that both 5EuHAp suspensions and coatings exhibited noticeable antifungal activity against C. albicans cells.

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.

Severe polymicrobial and fungal periprosthetic osteomyelitis persisting after hip disarticulations treated with caspofungin in risk patients: a case series

BACKGROUND

Periprosthetic fungal infections are considered rare and opportunistic infections. Treatment is difficult, and established standards do not yet exist. The choice of the appropriate antifungal drug might affect the patient outcome.

CASES

All the three cases presented showed polybacterial recurrent infection of the revision hip arthroplasty. All patients were of younger age, had multiple revisions of the endoprosthesis, each had a large partial femoral replacement greater than 40% of the femoral length, gentamycin-loaded cement, and a long anchoring distance of the used intramedullary stem. Due to the severe life-threatening infection with deep osteomyelitis, an amputation had to be performed. However, despite surgical intervention, the fungal dominated infection persisted. Finally, only the use of caspofungin allowed permanent infection control.

CONCLUSION

The polybacterial infection is driven by the symbiosis between fungi and bacteria. Therefore, eradication of the fungus is required to achieve elimination of the bacteria. Antimycotics of the echinocandin-class, such as caspofungin, may be considered as initial treatment.

Candida fracture-related infection: a systematic review

Background: The aim of this study is to summarize and improve knowledge regarding a Candida fracture-related infection (CFRI) through a systematic review on the topic, accompanied by a case report. Methods: A systematic review and meta-analysis based on PRISMA statement were conducted on the CFRI topic. The following combined search terms were used to explore PubMed, Cochrane, and the Embase database: "fungal infection", "candida", "fracture related infection", "bone infection", "orthopedic infection", "internal fixation", "post-traumatic infection", and "osteomyelitis". Results: Out of 1514 records, only 5 case reports matched the selection criteria and were included. Moreover, a new case of CFRI, not previously described, was reported in this paper and reviewed. The main risk factors for CFRI were open wounds (three cases) and immunodeficiency (three cases). Initial improvement of clinical and laboratory signs of infection was noted in all cases. In the available short-term follow-up (mean 12.1 months; range 3-42), the reoperation rate was 33.3 %. Using a strategy based on extensive debridement/resection methods and prolonged systemic antifungal therapy (mean 8.8 weeks; range 6-18), four of six cases (66.6 %) were cured. Bone union occurred in three out of six cases. Conclusion: There is very low-quality evidence available regarding CFRI. Candida infections in surgically treated fractures are rare but difficult-to-treat events, with a slow onset, unspecific symptoms or signs, and a significant relapse risk; therefore, they still represent a current diagnostic challenge. The existing fracture-related infection treatment algorithm combined with long-term systemic antifungal therapy has an anecdotal value and needs more extensive studies to be validated.

Three-stage revision arthroplasty for the treatment of fungal periprosthetic joint infection: outcome analysis of a novel treatment algorithm : a prospective study

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.

Aspergillus PJI - A systematic analysis of all known cases and report of a new one

Fungi resemble less than one percent of all periprosthetic joint infections (PJI). While Candida PJI is well described, Aspergillus PJI has only been reported in a few cases without any systematic analysis present at this point. This review aims to systematically summarize and describe all cases of Aspergillus PJI. The systematic review used PubMed and Cochrane Library to identify case reports and studies eligible for inclusion. One additional case was reported by the authors. T-, Mann-Whitney U- and Fisher-exact tests were used for calculations. Overall, 11 cases of Aspergillus PJI were identified, and ten could be included for a detailed analysis (four hip, four knee, one elbow, one PIP-arthroplasty infection). A. fumigatus was identified in four, A. terreus in three, and A. niger in two cases. The average patient age at time of Aspergillus spp. diagnosis was 64.1 years (32-83) and the mean time from primary implantation to Aspergillus PJI 5.2 years (1-16). The calculated CCI was 2.7 (0-6). Surgery included one-, two-, three-stage-, and spacer-exchange, debridement and resection arthroplasty. Four patients were treated with a triazole for an average of three months, three with amphotericin (mean eight weeks), one with both amphotericin (six weeks) and triazole (seven months). In one patient, reinfection with Coagulase Negative Staphylococci following Aspergillus PJI treatment was noted after four years. A. terreus (p = .048) was associated with failed prosthesis reimplantation (n = 4). To give a resume, Aspergillus PJI is a rare, yet severe complication, with heterogeneous clinical presentation. Complete prosthesis removal is the treatment of choice.

A systematic review on the implication of Candida in peri-implantitis

Background

Candida is a heterogeneous fungal genus. Subgingival sulcus is a refuge for Candida, which has already been related to the pathogenic inflammation of periodontitis. This work aims to review the presence of Candida in the sulcular fluid surrounding dental implants and discuss its potential role in peri-implantitis.

Results

A bibliographical research was performed in PubMed, Scopus and Web of Science databases, with the keywords candida, peri-implantitis, periimplantitis, “dental implant” and implant. Newcastle-Ottawa Scale was used to assess the methodological quality of the included studies. At the end, nine observational studies were included, which analysed 400 dental implants with PI and 337 without peri-implantitis. Presence of Candida was assessed by traditional microbiological culture in blood agar or/and CHROMagar, though identification was also detected by quantitative real-time PCR, random amplified polymorphic DNA or ATB ID 32C. Dentate individuals and implants with peri-implantitis (range, 3–76.7%) had a bigger presence of Candida. C. albicans was the most isolated species, followed by Candida parapsilosis, Candida tropicalis, and Candida dubliniensis.

Conclusion

Candida is part of the microbiological profile of the peri-implant sulcular fluid. More studies are needed to compare the link between Candida and other microorganisms and to discover the true role of these fungi in peri-implantitis.

Periprosthetic Fungal Infections in Severe Endoprosthetic Infections of the Hip and Knee Joint-A Retrospective Analysis of a Certified Arthroplasty Centre of Excellence

The treatment of periprosthetic joint infections (PJI), and especially of re-infections, poses a highly complex problem in orthopaedic surgery. While fungal infections are rare, they present a special challenge. The therapy is often protracted and based on limited evidence. A total of 510 hip and knee revision surgeries were analysed for the occurrence of bacterial and fungal PJI. In patients with PJI, the duration of the hospital stay and the incidence of disarticulation of the infected joint were recorded. Out of the analysed revision arthroplasties, 43.5% were due to PJI. Monomicrobial infection occurred in 55.2%, dual microbial infection in 21.4%, and polymicrobial (≥3 different bacterial or fungal species) infection in 17.2% of the cases. Overall, Candida species were detected in 12.4% cases. Candida albicans was the main fungal pathogen. In 6.9% of cases, disarticulation of the joint was the only option to control PJI. The detection of polymicrobial infection more than doubled in follow-up revisions and there was a strong association between detection of Candida infection and disarticulation (OR 9.39). The majority of fungal infections were mixed infections of bacteria and Candida albicans. The choice of a biofilm penetrating antimycotic, e.g., caspofungin, together with a sufficient standard procedure for detection and surgical treatment can help to control the infection situation. Fungal infection often proves to be more difficult to treat than anticipated and is more frequent than expected.

A spacer infection by Candida albicans secondary to a Staphylococcus capitis prosthetic joint infection: a case report

BACKGROUND

Prosthetic joint infection (PJI) is one of the most feared complications following total arthroplasty surgeries. Gram-positive bacteria are the most common microorganisms implicated in PJIs, while infections mediated by fungi only account for 1% of cases. When dealing with PJIs, a two-stage revision arthroplasty is widely used. Briefly, a spacer is introduced until re-implantation of the definitive prosthesis to provide skeleton stabilization while delivering antibiotics in the site of the infection. Sometimes, antimicrobial therapy may fail, but the isolation of a second microorganism from the spacer is uncommon and even less frequent that of a yeast.

CASE PRESENTATION

Here is described a case of a 75-year-old woman who underwent two-stage revision surgery of the left hip prosthesis secondary to a Staphylococcus capitis infection, whose spacer was found to be infected by Candida albicans at a later time. Briefly, the patient underwent revision surgery of the hip prosthesis for a suspected PJI. After the debridement of the infected tissue, an antibiotic-loaded spacer was implanted. The microbiological analysis of the periprosthetic tissues and the implant depicted a S. capitis infection that was treated according to the antimicrobial susceptibility profile of the clinical isolate. Three months later, the patient was admitted to the emergency room due to local inflammatory signs. Synovial fluid was sent to the laboratory for culture. No evidence of S. capitis was detected, however, a yeast was identified as Candida albicans. Fifteen days later, the patient was hospitalized for the removal of the infected spacer. Microbiological cultures confirmed the results of the synovial fluid analysis. According to the susceptibility profile, the patient was treated with fluconazole (400 mg/day) for 6 months. Seven months later, the patient underwent second-stage surgery. The microbiological tests on the spacer were all negative. After 12 months of follow-up, the patient has fully recovered and no radiological signs of infection have been detected.

CONCLUSIONS

Given the exceptionality of this complication, it is important to report these events to better understand the clinical outcomes after the selected therapeutic options to prevent and forestall the development of either bacterial or fungal spacer infections.

Candida Periprosthetic Joint Infection: Is It Curable?

Candida periprosthetic joint infection (CPJI) is a rare and very difficult to treat infection, and high-quality evidence regarding the best management is scarce. Candida spp. adhere to medical devices and grow forming biofilms, which contribute to the persistence and relapse of this infection. Typically, CPJI presents as a chronic infection in a patient with multiple previous surgeries and long courses of antibiotic therapy. In a retrospective series of cases, the surgical approach with higher rates of success consists of a two-stage exchange surgery, but the best antifungal treatment and duration of antifungal treatment are still unclear, and the efficacy of using an antifungal agent-loaded cement spacer is still controversial. Until more evidence is available, focusing on prevention and identifying patients at risk of CPJI seems more than reasonable.

Toward Designing of Anti-infective Hydrogels for Orthopedic Implants: From Lab to Clinic

An alarming increase in implant failure incidence due to microbial colonization on the administered orthopedic implants has become a horrifying threat to replacement surgeries and related health concerns. In essence, microbial adhesion and its subsequent biofilm formation, antibiotic resistance, and the host immune system's deficiency are the main culprits. An advanced class of biomaterials termed anti-infective hydrogel implant coatings are evolving to subdue these complications. On this account, this review provides an insight into the significance of anti-infective hydrogels for preventing orthopedic implant associated infections to improve the bone healing process. We briefly discuss the clinical course of implant failure, with a prime focus on orthopedic implants. We identify the different anti-infective coating strategies and hence several anti-infective agents which could be incorporated in the hydrogel matrix. The fundamental design criteria to be considered while fabricating anti-infective hydrogels for orthopedic implants will be discussed. We highlight the different hydrogel coatings based on the origin of the polymers involved in light of their antimicrobial efficacy. We summarize the relevant patents reported in the prevention of implant infections, including orthopedics. Finally, the challenges concerning the clinical translation of the aforesaid hydrogels are described, and considerable solutions for improved clinical practice and better future prospects are proposed.

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.

Candida albicans-The Virulence Factors and Clinical Manifestations of Infection

Candida albicans is a common commensal fungus that colonizes the oropharyngeal cavity, gastrointestinal and vaginal tract, and healthy individuals' skin. In 50% of the population, C. albicans is part of the normal flora of the microbiota. The various clinical manifestations of Candida species range from localized, superficial mucocutaneous disorders to invasive diseases that involve multiple organ systems and are life-threatening. From systemic and local to hereditary and environmental, diverse factors lead to disturbances in Candida's normal homeostasis, resulting in a transition from normal flora to pathogenic and opportunistic infections. The transition in the pathophysiology of the onset and progression of infection is also influenced by Candida's virulence traits that lead to the development of candidiasis. Oral candidiasis has a wide range of clinical manifestations, divided into primary and secondary candidiasis. The main supply of C. albicans in the body is located in the gastrointestinal tract, and the development of infections occurs due to dysbiosis of the residential microbiota, immune dysfunction, and damage to the muco-intestinal barrier. The presence of C. albicans in the blood is associated with candidemia-invasive Candida infections. The commensal relationship exists as long as there is a balance between the host immune system and the virulence factors of C. albicans. This paper presents the virulence traits of Candida albicans and clinical manifestations of specific candidiasis.

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.

Cryptococcus magnus Periprosthetic Shoulder Infection: A Case Report

CASE

We present a 68-year-old diabetic man with a periprosthetic shoulder infection (PSI) by Cryptococcus magnus. The fungus was identified 4 weeks after a revision surgery for a chronic bacterial PSI. Treatment was successful with a 2-week course of intravenous liposomal amphotericin B (5 mg/kg) followed by 6 weeks of fluconazole (200 mg/d).

CONCLUSION

To the best of our knowledge, only 2 periprosthetic infections due to Cryptococcus neoformans have been previously reported. This is the first report of cryptococcal involvement of a prosthetic shoulder, and the first identified osteoarticular infection ever by C. magnus.

Quantifying the relationship between surfaces' nano-contact point density and adhesion force of Candida albicans

It has been recently recognized that controlled surface structuring on the nanometer scale is a successful strategy to endow different materials with antimicrobial properties. Despite many studies on bacterial interactions with nanostructured surfaces, a quantitative link between surface topography and bacterial adhesion is still missing. To quantitatively link cell adhesion data with topographical surface parameters, we performed single-cell spectroscopy on chemically identical surfaces with controlled nano-contact point density achieved by immobilization of gold nanoparticles (AuNP) on gold thin films. Such materials surfaces have previously shown antimicrobial (anti-adhesive) efficacy towards Gram-negative Escherichia coli cells. In the current study, the influence of nano-structured surfaces on the surface coverage and adhesion forces of clinically relevant Candida albicans (C. albicans), the fungus primarily associated with implant infections, was investigated to validate their antimicrobial potency against different microbial cells. The adhesion forces of C. albicans cells to nanostructured surfaces showed a decreasing trend with decreasing contact-point density and correlated well with the results of the respective C. albicans cell counts. The surfaces with the lowest contact-point density, 25 AuNP/μm², resulted in an average adhesion force of 5 nN, which was up to 5 times lower compared to control and 61 AuNP/μm² surfaces. Further, detailed analyses of force-distance curves revealed that the work of adhesion, and thus the energy required to remove the C. albicans cell from the surface is up to 10 times lower on 25 AuNP/μm² surfaces compared to unstructured surfaces. These findings show that a controlled tuning of nanostructured surfaces in terms of accessible nano-contact points is crucial to generate surface structures with enhanced antimicrobial properties. The gained knowledge can be further exploited for the design of biomaterials surfaces to prevent adhesion of some most commonly encountered pathogens.

Recommendations for Systemic Antimicrobial Therapy in Fracture-Related Infection: A Consensus From an International Expert Group

Fracture-related infection (FRI) is a major complication in musculoskeletal trauma and one of the leading causes of morbidity. Standardization of general treatment strategies for FRI has been poor. One of the reasons is the heterogeneity in this patient population, including various anatomical locations, multiple fracture patterns, different degrees of soft-tissue injury, and different patient conditions. This variability makes treatment complex and hard to standardize. As these infections are biofilm-related, surgery remains the cornerstone of treatment, and this entails multiple key aspects (eg, fracture fixation, tissue sampling, debridement, and soft-tissue management). Another important aspect, which is sometimes less familiar to the orthopaedic trauma surgeon, is systemic antimicrobial therapy. The aim of this article is to summarize the available evidence and provide recommendations for systemic antimicrobial therapy with respect to FRI, based on the most recent literature combined with expert opinion. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Prosthetic Joint Infection of a Revision Knee Arthroplasty with Candida parapsilosis

We report a case of an infected total knee arthroplasty with Candida parapsilosis. The patient was successfully treated with a two-stage exchange arthroplasty, local antifungal treatment, and systemic antifungal treatment. This specific combination therapy to treat C. parapsilosis joint infection has not been previously reported.

Diagnosis and Management of Fungal Periprosthetic Joint Infections

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.

Successful treatment of a Candida auris intra-articular infection

A 78-year-old woman with a long-term ankle spacer with antibacterials developed an intra-articular Candida auris infection. Treatment with systemic antifungal therapy plus an amphotericin B moulded cement spacer was successful.

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.

Culturing periprosthetic tissue in BacT/Alert® Virtuo blood culture system leads to improved and faster detection of prosthetic joint infections

Background

Blood culture bottles (BCBs) provide a semiautomated method for culturing periprosthetic tissue specimens. A study evaluating BCBs for culturing clinical samples other than body fluids is needed before implementation into clinical practice. Our objective was to evaluate use of the BacT/Alert® Virtuo blood culture system for culturing periprosthetic tissue specimens.

Methods

The study was performed through the analysis of spiked (n = 36) and clinical (n = 158) periprosthetic tissue samples. Clinical samples were analyzed by the BCB method and the results were compared to the conventional microbiological culture-based method for time to detection and microorganisms identified.

Results

The BacT/Alert® Virtuo blood culture system detected relevant bacteria for prosthetic joint infection in both spiked and clinical samples. The BCB method was found to be as sensitive (79%) as the conventional method (76%) (p = 0.844) during the analyses of clinical samples. The BCB method yielded positive results much faster than the conventional method: 89% against 27% detection within 24 h, respectively. The median detection time was 11.1 h for the BCB method (12 h and 11 h for the aerobic and the anaerobic BCBs, correspondingly).

Conclusion

We recommend using the BacT/Alert® Virtuo blood culture system for analyzing prosthetic joint tissue, since this detect efficiently and more rapidly a wider range of bacteria than the conventional microbiological method.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4206-x) contains supplementary material, which is available to authorized users.

Two-stage revision and systemic antifungal therapy of Candida glabrata primary prosthetic hip infection successfully treated: a case report

BACKGROUND

Overall, fungi are estimated to cause approximately 1% of prosthetic joint infections, Candida glabrata account for less than 10% of these cases. No well-defined treatment strategy is available.

CASE PRESENTATION

A 71-year-old Caucasian man with non-insulin-dependent diabetes was admitted for hip prosthesis revision. For the past 17 years he suffered from recurrent infection of a perianal fistula, the last episode being 1 week before admission, and was prescribed amoxicillin/clavulanate 1 g twice a day. At surgery, the synovial fluid tested positive for infection with the Synovasure® Alpha Defensin Test, and the orthopedic surgeon reported intraoperative evidence of infection. While the synovial fluid failed to grow microorganisms, seven different samples including periprosthetic tissue and the prosthesis grew Candida glabrata. Imipenem 2 g and teicoplanin 600 mg daily were administered during surgery. Also an antibiotic loaded spacer was positioned. A week later micafungin 100 mg a day was added, and after another week imipenem was replaced with ertapenem 1 g once a day. The combination of antibiotics and antifungal was administered for a total of 7 weeks, while he also underwent treatment of the perianal fistula. The reimplantation was performed after an 8-week antibiotic-free interval. Before reimplantation, his erythrocyte sedimentation rate and C-reactive protein level were normal. At reimplant surgery, several samples were collected for microbiology, before administering ertapenem 1 g, teicoplanin 600 mg and micafungin 100 mg once a day. This antimicrobial combination was continued for 15 days until the microbiologic investigations, including culture and molecular testing after sonication technique of the spacer, were reported negative for bacteria and fungi. In this patient, systemic antifungal and extensive debridement allowed for clinical and microbiologic cure.

CONCLUSIONS

Although Candida glabrata prosthetic joint infection is a rare event, the incidence could increase in the future, and there is need for more definitive treatment protocols. Diagnosis depends on culture. Fungal etiology must always be included in the differential diagnosis of prosthetic joint infection.

Two-Stage Exchange Arthroplasty Is a Favorable Treatment Option Upon Diagnosis of a Fungal Periprosthetic Joint Infection

BACKGROUND

This study investigated the prevalence of medical comorbidities, risk factors, and treatment outcomes in patients with fungal periprosthetic joint infection (PJI).

METHODS

All patients with fungal PJI treated from 1999 to 2014 were retrospectively identified at a single institution. Demographic data, comorbidity, and surgical variables were obtained from medical records. Patients were followed up for at least 2 years. PJI was diagnosed using the Musculoskeletal Infection Society criteria. Treatment success was defined using the Delphi consensus criteria. Kaplan-Meier survivorship curves with 95% confidence interval were used for analysis.

RESULTS

Overall, fungal PJIs accounted for 2.4% of the PJI treated at our institution. Twenty-seven patients (93.1%) had 2 or more underlying systemic illnesses. Age and revision surgery were significant risk factors for development of fungal PJI after adjusting for confounding variables. Overall treatment success was 55.2% at 1 year and 40.5% at 5 years. When stratified by initial surgical management, treatment success was 57.1% at 1 year and 28.6% at 5 years following irrigation and debridement; 33.3% at 1 year and 5 years following 1-stage revision; and 57.9% at 1 year and 46.3% at 5 years for 2-stage exchange arthroplasty.

CONCLUSION

Patients with fungal PJI have a high prevalence of systemic illness and poor outcome after surgical management. Irrigation and debridement and single-stage revision demonstrate poor longterm outcomes and may have no place as treatment choices for fungal PJI. Moving forward, our efforts should concentrate on optimizing the systemic status of these patients prior to 2-stage exchange arthroplasty.

Candida periprosthetic joint infection: A rare and difficult-to-treat infection

BACKGROUND

Candida periprosthetic joint infection (CPJI) is a rare, difficult-to-treat disease. The purpose of this study was to evaluate the clinical characteristics and outcomes of CPJI treated with various surgical and antifungal strategies.

METHODS

We conducted a multicenter retrospective study of all CPJI diagnosed between 2003 and 2015 in 16 Spanish hospitals.

RESULTS

Forty-three patients included: median age, 75 years, and median Charlson Comorbidity Index score, 4. Thirty-four (79.1%) patients had ≥1 risk factor for Candida infection. Most common causative species were C. albicans and C. parapsilosis. Thirty-five patients were evaluable for outcome: overall, treatment succeeded in 17 (48.6%) and failed in 18 (51.4%). Success was 13/20 (67%) in patients with prosthesis removal and 4/15 (27%) with debridement and prosthesis retention (p = 0.041). All 3 patients who received an amphotericin B-impregnated cement spacer cured. In the prosthesis removal group, success was 5/6 (83%) with an antibiofilm regimen and 8/13 (62%) with azoles (p = 0.605). In the debridement and prosthesis retention group, success was 3/10 (30%) with azoles and 1/5 (20%) with antibiofilm agents. Therapeutic failure was due to relapse in 9 patients, need for suppressive treatment in 5, persistent infection in 2, and CPJI-related death in 2; overall attributable mortality was 6%.

CONCLUSIONS

CPJI is usually a chronic disease in patients with comorbidities and risk factors for Candida infection. Treatment success is low, and prosthesis removal improves outcome. Although there is insufficient evidence that use of antifungals with antibiofilm activity has additional benefits, our experience indicates it may be recommendable.

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.