Abstract
Introduction
Fungi are a rare and devastating cause of Periprosthetic Joint Infection (PJI). Diagnosis and treatment is a challenge as there are currently no specific guidelines. A recently published review identified 75 case reports of fungal PJI.
Aim
The aim is to describe our experience of treating fungal PJI since 2011 within the Bone Infection Unit at our institution.
Methods
A retrospective observational study including all patients who have received systemic or local antifungal treatment for PJI. Data was collected from electronic patient notes and databases.
Results: We identified 10 patients who were treated for fungal PJI between May 2011 and March 2017.
Demographics: Of the 10 patients, 7 were female and 3 were male. The mean age was 68 with a range of 19 to 87. The types of prosthesis infected were total knee (n=4), proximal femoral (n=2), total hip (n=1), distal femoral (n=1), total shoulder (n=1) and distal humoral (n=1) replacements. Organisms requiring treatment were all Candida species, including; C. albicans (n=3), C. parapsilosis (n=3), C. dublinensis (n=2), C. orthopsilosis (n=1) and C. glabrata (n=1).
Treatment
Of the 10 patients, 8 had a 2-stage revision and 2 had single stage revision surgery.
Local antifungal delivery using cement spacers loaded with voriconazole (300mg per 40g of bone cement), were used in all of the 5 cases where the fungi were identified prior to revision surgery.
Initial systemic antifungal treatment continued for a mean duration of 2.6 months (range 0.9 to 8.4), and included caspofungin (n=4), fluconazole (n=6) and voriconazole (n=1). Of the 6 patients initially treated with azole antifungals, 3 patients required a change of antifungal treatment due to raised liver function tests.
Clinical outcome
Outcome was established by the absence or presence of clinical signs of infection at a mean follow-up of 13.2 months (range 1 to 29). Of the 8 patients who had a 2-stage revision, 5 had a successful outcome, 2 were awaiting follow up to assess outcome and 1 was unsuccessful (required amputation). Of the patients who had a single stage revision, 1 was successful and there was 1 patient death (due to pulmonary embolism).
Conclusion
Our case series supports current evidence supporting a two-stage revision strategy for fungal PJI. In this series caspofungin was better tolerated than azole antifungals.
