Non-albicans Candida prosthetic joint infections: a systematic review of treatment

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.

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 PJIs are a relatively infrequent [ 7 , 8 ], albeit potentially devastating, complication of joint replacement surgery [ 9 ] reported to account for just 1.45–3.1% of all confirmed infections involving primary TKAs or THAs [ [10] , [11] , [12] ]. The rate has been proposed to be higher in the re-revision setting.…”

“…The rate has been proposed to be higher in the re-revision setting. Previous investigations have suggested that Candida albicans represents the most commonly encountered periprosthetic fungal infection of the knee (80–88% of cases) [ 8 , [13] , [14] , [15] ], with non-Candida species PJIs considered relatively rare [ 9 ]. While “classic” descriptions have inferred an underlying immunocompromised host requirement, recent review of the literature did not support this in most cases [ 16 ].…”

“…A high index of suspicion is required such that these important synergistic infective processes are not overlooked [ 16 ]. While the mean time to onset of symptoms for a fungal PJI after index surgery is reported to be 27.2 months [ 9 ], the average time to definitive diagnosis is a further 7.5–20 months thereafter [ 13 , 22 ]. These infections are recognized as being difficult to diagnose and treat [ 8 , 20 , 23 ], with patients having endured an average of 2.7 operations before definitive pathogen identification [ 13 , 23 ].…”

“…These infections are recognized as being difficult to diagnose and treat [ 8 , 20 , 23 ], with patients having endured an average of 2.7 operations before definitive pathogen identification [ 13 , 23 ]. Once diagnosed, there exist no universal guidelines for the targeted management of fungal PJIs [ 9 , 13 , 20 , 24 , 25 ]. Despite a raft of varied approaches, fungal PJIs are associated with poorer outcomes [ 12 ] vs comparable bacterial infections; clearance (ie, cure) rates are lower [ 7 ] with far higher secondary failure rates [ 18 , 23 ], conversions to resection arthroplasties [ 7 , 23 ], amputation rates [ 17 ], and associated mortality [ 7 , 16 ].…”

Fungal Infection following Total Elbow Arthroplasty

“…We present a previously unreported case of fungal PJI with the organism C. parapsilosis following a TEA. Most PJIs, including those involving the shoulder, hip and knee, are caused by the organisms Staphylococcus aureus and S epidermidis , whereas fungal organisms represent a mere 1% of the etiologies, with the Candida species being the most common [1, 3, 5–10]. The decision to perform an initial surgical debridement, bushing exchange, and implant retention was based on the well-fixed implants, minimal patient symptoms, and the concern for bone loss in the setting of elbow explantation [11].…”