Prosthetic joint infection due to Candida species

Abstract

Introduction: The increase in the number of patients with prosthetic joints will entail a rise in the absolute number of infections associated with these procedures. Although less frequent, infections by Candida species are also expected to increase, and the clinical and surgical management of these cases is based on case reports and opinion of specialists. The objective of the present study was to review the available literature and describe the cases of prosthetic joint infection caused by Candida species in patients of the Institute of Orthopedics and Trauma of the University of São Paulo Faculty of Medicine Clinics Hospital (IOT-HCFMUSP) between 2007 and 2014. Patient concerns: Eleven patients were diagnosed with prosthetic joint infection due to Candida with mean age of 65 years. The most frequent comorbidities were heart disease and diabetes mellitus, and the main personal antecedent was previous bacterial infection in the prosthetic joint. At least one risk factor for fungal infection was present in 73% of the patients. There was no difference between the prevalence of infections caused by Candida albicans and non-albicans Candida species, and there was bacterial co-infection in 55% of the cases. Diagnosis: For building up the case series, patients with cultures of bone and joint specimens that were positive for Candida species and had a clinical diagnosis of prosthetic joint infection were included in the case series. Interventions: Surgical debridement with removal of the prosthesis was the most frequently used surgical approach (45%). All patients were treated with monotherapy, and the most frequently used antifungal agent was fluconazole. The total duration of antifungal therapy was 6 months in 73% of the cases. Outcomes: After the initial management, 73% of the patients achieved clinical remission. Conclusion: The most indicated initial management was debridement with removal of the prosthesis, and the most used treatment regimen was fluconazole monotherapy. The most prevalent treatment duration was 6 months. The initial management led to a favorable outcome in 73% of the cases. Descriptors: Prosthetic joint infection, Candida, treatment, and diagnosis.

Risk factors affect success rate of debridement, antibiotics and implant retention (DAIR) in periprosthetic joint infection

“…As people pay more attention to the PJI, the infection rate following arthroplasty is decreasing. However, the increase in the number of patients with prosthetic joints in recent decades has added to the absolute number of PJI cases [ 3 , 4 ]. Recently, a review showed that, with more arthroplasty cases, the cost of revision surgery for infection has put greater pressure on healthcare budgets [ 5 ].…”

Candida Periprosthetic Joint Infection: Is It Curable?

“…Other species, such as C. glabrata and C. tropicalis, were more anecdotic (3–7% and 2–4%, respectively). Smaller series have found similar results [ 13 , 14 ], and in a recent review of the literature, C. albicans (47.3%) was the most frequent strain isolated, followed by C. parapsilosis (22.3%) [ 15 ], but epidemiology may still vary among regions.…”

“…(3) Immunosuppression secondary to malignant diseases, immunodeficiencies, or immunosuppressive therapy. Other risk factors reported in patients with CPJIs have been older age [ 18 ], diabetes, rheumatoid arthritis, malnutrition, and tuberculosis, which probably also reflect alterations in host immunity [ 2 , 12 , 13 , 14 , 23 ]. Other series have also identified that multiple previous surgeries at the site of the CPJI are also a risk factor [ 2 , 13 , 23 , 24 ].…”

“…Therefore, the best surgical approach is to remove the prosthetic material to avoid the problem of antifungals penetrating and acting within the biofilm. In this sense, a two-stage exchange arthroplasty strategy is probably the best option when feasible to eradicate the infection and to preserve joint function [ 15 ], with variable success rates from 14% to almost 100% depending on the series and on the definition of success [ 2 , 12 , 14 , 23 , 24 , 25 , 31 , 32 , 33 , 34 , 35 ]. In patients with reduced mobility, particularly old patients with multiple previous surgeries in the same location, a resection arthroplasty may be the best alternative.…”

“…There is less evidence of success with a one-stage exchange arthroplasty strategy, which has been reported in only a few cases [ 15 , 36 , 37 ]. In a recent review of the literature of 76 episodes of CPJI, one-stage exchange arthroplasty was performed only in three patients with a favorable outcome [ 15 ], but in another series of 11 CPJI episodes, it was performed in four with success in two [ 14 ]. However, due to the publication bias, the small amount of experience and the difficulty of curing this type of infection, with a high rate of relapses, in our opinion, this procedure should be used only in very selected cases.…”