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

Abstract

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.

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

“…A total of 63 studies on fungal PJI were found. A total of 372 fungal PJI cases were retrieved, most of which were collected from case reports [12,14,, small case series [15,[63][64][65][66][67][68][69][70][71], and only a few from cohort studies with larger samples [3][4][5]8,11,[72][73][74][75][76] (Table 1) Two studies reported an incidence of fungal PJI of 1.9% [8] and 12.4% [73] in the whole PJI cohort.…”

“…Only a few publications described the detection rate of fungi in PJIs in total, reporting a 0.9–2.0% rate [ 8 , 74 , 81 , 82 , 83 ]. However, Enz et al observed [ 73 ] a much higher incidence of fPJI, detecting a fungus in 12.4% of the whole PJI cohort.…”

Periprosthetic Joint Infections Caused by Candida Species—A Single-Center Experience and Systematic Review of the Literature

“…A total of 12 studies comprising 153 cases of Candida PJI were included in the final analysis ( Table 2 ) [ 12 , 21 , 22 , 23 , 24 , 25 , 26 , 32 , 33 , 34 , 35 , 36 ]. The number of hip-to-knee PJI was 86 (54.8%) to 67 (46.2%), respectively.…”

“…However, one-stage surgical strategies are also performed with good results in different orthopedic centers [ 21 , 22 ]. Recently, several valuable studies concerning Candida PJIs were published [ 12 , 23 , 24 , 25 , 26 ] but not included in currently available systematic reviews [ 17 , 27 ].…”

Experimental Investigation of Material Transfer on Bearings for Total Hip Arthroplasty—A Retrieval Study on Ceramic and Metallic Femoral Heads

“…A possible source could be in the biofilm formed by colonizing bacteria [ 41 ]. The bacterial pathogens detected in the revisions Staphylococcus aureus and Enterococcus faecalis are among the most common pathogens in septic revisions [ 42 ]. Some studies showed that sulfide is an important component of the microbial sulfur cycle and S. aureus can use hydrogen sulfide to protect against cationizing molecules from antibiotics [ 43 , 44 , 45 ].…”