Diagnosis and Management of Fungal Periprosthetic Joint Infections

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, onestage 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.M ore than 1 million total joint arthroplasties (TJAs) are performed in the United States annually, 1 with notable increases projected over the next few decades. 2 With the increasing number of TJAs, periprosthetic joint infections (PJIs) are projected to increase over time. Although notable improvements have reduced the rate of PJI, 3 infection still remains a common cause of revision TJA. 4 Although gram-positive organisms are responsible for most PJIs, 5 fungal infections are increasing in prevalence. 6 Fungal PJI represents 1% of all joint infections, and its diagnosis may be more difficult compared with bacterial pathogens because of diverse clinical presentations. Sur-gical and medical management of fungal PJI are more challenging than gram-positive or negative infections because patients are often immunocompromised with a higher risk of persistent infection. Although increased attention has been dedicated to the diagnosis and management of bacterial septic joints, no standardized guidelines exist for the diagnosis and management of fungal PJI because of its rarity. It is unknown if the protocol for treating bacterial PJI can also be extrapolated to fungi, as there is inconsistent data with regards to the use of systemic, local and oral antifungal agents. This review carefully outlines the diagnosis and management options for fungal PJI.

Prosthetic Joint Infection of a Revision Knee Arthroplasty with Candida parapsilosis

“…Chance of failure (persistent infection) after surgical and antifungal treatment is 15-23% [5,6,8]. These infections often occur in immunocompromised patients (our patient has a medical history of rheumatoid arthritis) and patients who underwent previous surgeries of the affected joint (which also applies to our patient) [4][5][6]. We therefore considered this PJI difficult to treat.…”

“…We therefore considered this PJI difficult to treat. Following standard PJI guidelines and current literature on fungal PJIs [4,5], the patient was therefore treated with a two-stage exchange arthroplasty. This treatment regimen involved removal of the implant, a rigorous surgical debridement, placement of a spacer supplemented with antifungals mixed with the bone cement, and a new combination of systemic antifungal therapy.…”

“…Isolating the infecting organism can be a challenge with fungi, and repeated joint aspiration may be needed [4]. Management of fungal PJI, surgical as well as therapeutic, is considered more challenging due to the higher risk of persistent infection [5]. Current literature advises a two-stage exchange arthroplasty, combined with local and systemic antifungal therapy to manage fungal PJI [3][4][5][6][7].…”

“…Systemic as well as local antifungals can be used in medical treatment of the fungal PJI. Most frequent agents for a systemic treatment are fluconazole and amphotericin B given either orally or intravenously [4,5]. Local antifungal agent administration can be applied by implanting an impregnated cement spacer, by placing intra-articular powder, or by daily intra-articular lavage.…”

“…PJIs with fungi are referred to as difficult to treat, and treatment has not yet been well described [1,3,5,7]. Relatively few case reports and literary reviews have been published assessing a fungal PJI, mostly following different treatment regimens.…”