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

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.

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

“…In this case, the patient PJI was an early infection (less than 4 weeks) and was successfully treated with DAIR; however, the more robust and widely accepted approach remains 2-stage revision surgery. [26] The current literature does not strongly support retained prosthesis debridement for fPJI treatment, primarily due to its indolent performance that often results in late diagnosis. [26] Acute onset of infection is comparatively rare, accounting for only 5 out of 18 DAIR cases with reported time intervals.…”

“…[26] The current literature does not strongly support retained prosthesis debridement for fPJI treatment, primarily due to its indolent performance that often results in late diagnosis. [26] Acute onset of infection is comparatively rare, accounting for only 5 out of 18 DAIR cases with reported time intervals. However, an 80% success rate was associated with fPJI cases detected within 2 months of primary surgery and treated with DAIR (Table 1), suggesting that patients with early fungal infections may still be good candidates for prosthesis retention.…”

“…Candida species are the most common fungi found in fPJI cases, with Candida parapsilosis identified in the current case accounting for approximately 27% of all cases in the literature. [26] Fortunately, the microorganism in this case is easier to manage compared to Candida albicans, which can form complex biofilms. [67,68] Brooks et al [54] reported a total knee case infected with Candida parapsilosis that was ultimately cured with a DAIR procedure despite being categorized as a late infection.…”

“…Most patients with PJI present 1 or more specific risk factors, such as immunosuppression, obesity, diabetes, multiple previous revision surgeries, long-term antibiotic treatments, or even surgical season. [22][23][24][25][26][27] Recent findings indicate that nutritional status, particularly albumin levels, plays a crucial role in PJI management. Hypoalbuminemia may contribute to increased failure rates in treatment outcomes.…”

“…[48] Many researchers believe that 1- or 2-stage revisions are required in most fPJI cases, as the majority of these cases present mild clinical symptoms and are often diagnosed late. [26] One-stage revision surgery offers the advantages of requiring only 1 operation, reducing the duration of antibiotic therapy, and decreasing the risk of liver and kidney failure, hospitalization time, and financial costs. Conversely, 2-stage revision is considered the “gold standard” for PJI treatment, providing the surgeon with a sufficient interval to achieve an adequate antimicrobial treatment cycle for the patient.…”