Abstract
Aim
Optimal strategies for surgical and antimicrobial management of Candida periprosthetic joint infections (PJI) are unclear. We present a retrospective case series of patients diagnosed with PJI caused by Candida spp.
Method
Patients treated at our institution with Candida PJI from 01/2017 to 04/2018 were retrospectively included with isolation of Candida spp. in synovial fluid, intraoperative tissue or sonication fluid culture. PJI was defined by the proposed European Bone and Joint Infection Society (EBJIS) criteria. Treatment failure was defined as relapse or persistence of infection.
Results
We included 9 patients (4 men and 5 women, mean age 75 years) involving 4 knee and 5 hip joint prosthesis. Risk factors for Candida PJI were prior PJI (n=4), diabetes mellitus (n=3), chronic kidney disease (n=3), obesity (n=3), negative-pressure wound therapy (n=3), rheumatoid arthritis (n=1) and chronic decubitus (n=1). Two patients had no risk factors for Candida PJI identified. Infection was acquired postoperatively (n=7), hematogenously (n=1) or contiguously through communicating vesico-articular sinus (n=1). The causative pathogen was C. albicans in 5, C. parapsilosis in 3, C. tropicalis in 1 patient, isolated from periprosthetic tissue samples (n=7), sonication fluid (n=3) and blood cultures (n=2); bacterial co-pathogens were isolated in 8 patients. Histopathological analysis revealed low-grade inflammation in all 6 patients, in whom it was performed. All patients were treated with oral fluconazole for 3 months, two initially received intravenous caspofungin and three received suppression with oral fluconazole for additional 9 months (total treatment 12 months). Liposomal amphotericin B (300–700 mg per 40 g bone cement) was admixed to spacer cement in 3 patients. Debridement and prosthesis retention was performed in one patient with tumor prosthesis after bone resection due to osteochondrosarcoma. In the remaining 8 patients the prosthesis was removed, with one-stage reimplantation in 1 patient and two-stage reimplantation in 3 patients (after 6 weeks, 3 months and 7 months); two patients are currently awaiting reimplantation, one died due to reason not related to PJI and another underwent knee arthrodesis. Among 5 patients with prosthesis in place, relapse occurred in one patient with prosthesis retention. Another patient experienced new PJI of the exchanged prosthesis caused by Staphylococcus aureus.
Conclusions
All Candida PJI presented as chronic infection with low-grade inflammation. Treatment with prostheses retention failed, whereas in 4 patients who underwent two-stage exchange and long-term antifungal suppression, no relapse or persistence of infection was observed. All patients received oral fluconazole for ≥3 months.
