Success Rate of Fungal Peri-Prosthetic Joint Infection Treated by 2-Stage Revision and Potential Risk Factors of Treatment Failure: A Retrospective Study

Abstract

BackgroundThe aim of this study was to investigate the success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and related factors of treatment failure to offer a better treatment protocol.Material/MethodsWe reviewed 18 joints (13 knees and 5 hips) of 17 patients (10 women and 7 men) diagnosed with fungal peri-prosthetic joint infection from January 2000 to June 2015 at our institute. The mean follow-up was 65.1 months (range, 25–129 months). All joints were treated with complete debridement, implantation of antifungal-loaded cement spacers, at least 6 weeks of parenteral antifungal agents, and delayed reimplantation.ResultsNotably, 15 joints were infected with Candida, and molds were isolated in 3 joints. The median duration of resection arthroplasty and reimplantation was 33.9 weeks (range, 12–132 weeks). Thirteen (10 knees and 3 hips, 72.2%) of the 18 joints (13 knees and 5 hips) had no recurrent or persistent infection, while the remaining 5 joints (3 knees and 2 hips, 27.8%) failed to control infection after reimplantation of prosthesis or spacer. The long interval between prosthesis resection and reimplantation (69 weeks vs. 23.1 weeks, p=0.240) and mixed bacterial infection (80% vs. 46.2%, p=0.314) were associated with higher failure rate.ConclusionsDebridement with the retention of the prosthesis is not an ideal treatment protocol for fungal peri-prosthetic joint infection; thus, a two-stage revision could be valid. We suggest that 6 weeks of parenteral antifungal agents are necessary, and 6 subsequent weeks of oral antifungal treatment is also important. We do not recommend that the two-stage revision be performed on patients who have more than 2 host risk factors.

Candida periprosthetic joint infections — risk factors and outcome between albicans and non-albicans strains

“…While there is broad consensus regarding treatment of bacterial PJI, there is paucity of data to validate an agreed upon treatment protocol for fungal PJI [16]. Besides prosthesis exchange surgery, single case reports have suggested implant retention or permanent resection arthroplasty of the hip and arthrodesis of the knee joint to be viable treatment options [17][18][19][20][21][22].…”

A Biodegradable Antifungal-Loaded Sol–Gel Coating for the Prevention and Local Treatment of Yeast Prosthetic-Joint Infections

“…Currently, two-stage exchange arthroplasty is considered the best treatment option, with success rates ranging from 50% to over 90% [ 13 , 14 ]. In a significant percentage of patients, however, final reimplantation cannot be completed due to the poor health of the patient or persistent infection, which increases the risk of therapeutic failure and mortality [ 15 , 16 ].…”

Candida Periprosthetic Joint Infection: Is It Curable?

“…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.…”

“…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. Irrigation and debridement with prosthesis retention usually fails to cure the infection (cure rates from 0% to 20%), especially in cases of chronic infection [ 2 , 12 , 23 , 32 , 35 ]. Table 1 summarizes the type of treatment, the duration of follow-up and the outcome of the larger case series (number of patients ≥ 10) of CPJI.…”

“…Moreover, there is no consensus on which antifungal agent should be used and at what dose to achieve the optimal balance between cement stability and drug elution. There have been some cases in which amphotericin B deoxycholate or an azole (mainly fluconazole or voriconazole) was mixed with the cement in the spacer [ 2 , 15 , 35 , 40 , 41 , 42 ], with different outcomes. In our clinical practice, amphotericin B (200 mg of amphotericin B deoxycholate for every 40 g of bone cement) is often used because of its broad antifungal spectrum and antibiofilm activity, its heat stability, and its availability in powder form.…”