Risk factors and the clinical and surgical features of fungal prosthetic joint infections: A retrospective analysis of eight cases

Abstract

Fungal prosthetic joint infections (PJI) and reports of their clinical investigation are rare. In addition, there has been little evidence regarding the outcome of the two-stage exchange protocol for the treatment of fungal PJI. In order to investigate the risk factors and clinical, microbiological and pathological features of fungal PJIs, as well as the effects of the two-stage exchange protocol on their outcome, the present study analyzed eight retrospective fungal PJI cases, involving four cases affecting the hips and four affecting the knees, between May 2000 and March 2012. In all cases, a cemented spacer saturated with antimicrobials was used during the two-stage exchange protocol, and systematic antifungal agents were administrated during the interim period. The average follow-up duration was 4.4 years. Of the eight cases, six had undergone additional surgery on the infected joint prior to infection with the fungus. Following histological analyses, it was determined that the average number of polymorphonuclear cells in the three patients infected with a fungus was only <5/high power field (HPF; magnification, ×400), and that of the five patients with a hybrid infection was >5/HPF. The average Harris Hip scores or Hospital for Special Surgery knee scores were 43.6 preoperatively and 86 at the last follow-up. The two-stage exchange protocol was performed eight times in seven cases, with a failure rate of 12.5%. The remaining case was successfully treated by resection arthroplasty. The average duration of antifungal agent administration during the interim period in five of the eight cases was 1.5 months. For three of the patients, the duration of antifungal agent administration was prolonged until the c-reactive protein levels were decreased to normal. The average duration of spacer implantation into the joint was 4.3 months. The results of the present study suggested that undergoing surgery on a prosthetic joint may be a potential risk factor for the development of fungal PJI. In addition, infiltration of polymorphonuclear leukocytes into the site of the infection may not occur at the same rate as bacterial PJI. Therefore, a two-stage exchange protocol with implantation of a cement spacer saturated with antimicrobials may be considered an effective therapeutic strategy for the treatment of fungal PJI.

Trends in microbiological profiles and antibiotic resistance in periprosthetic joint infections

“…The reason may be that some patients underwent artificial joint replacement surgery in another hospital, and they had already received treatment for PJI with broad-spectrum antibiotics and re-operation in those hospitals. 21 The small number of cases in our study may have affected the statistical analysis. A Spanish multicenter study also reported a significant increase in the incidence of PJI caused by fungi.…”

Risk Factors for Fungal Prosthetic Joint Infection

“…To our knowledge, this is the first study to establish an association between a patient's surgical history and subsequent development of fungal PJI. In a study done by Geng et al [28], which was a retrospective analysis of eight cases of fungal PJIs, six had undergone additional surgery on the infected joint following primary total joint arthroplasty and preceding diagnosis of fungal PJI. In a second smaller study from Spain, comprising 10 patients with fungal PJIs, nine had previous bacterial infections, received antibiotics for more than 15 days and required multiple surgeries [29].…”

Diagnosis and Management of Fungal Periprosthetic Joint Infections

“…A multicenter fungal PJI study of 31 patients reported an average ESR and CRP of 54 mm/hr and 17.5 mg/L, respectively. 7 Geng et al 9 reported an average ESR and CRP of 75 mm/hr and 6 mg/dl in 87.5% (7 of 8) of patients. Klatte et al 14 found patients with fungal PJI to have elevated mean CRP levels (22 mg/L; range 6-90.1 mg/L) with normal white blood cell (WBC) counts (mean, 5.7 cell/nL; range 4.6-8.0).…”

“…Multiple revision surgeries and prolonged hospitalizations also increased the risk of fungal PJI. 7,9 Among all the risk factors and associated comorbidities for fungal PJI, immunosuppression has the highest correlation with fungal infections because of its close association with the innate immune response. 10 Innate immune pattern recognition receptor cells mount a specific fungal response with C-type lectin receptors, pentraxin-3, and Toll-like receptors.…”