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Fungal PJI: More than just a prosthetic infection
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Management of periprosthetic joint infection is challenging on many accounts. Fungal periprosthetic joint infections are particularly difficult to treat. The problem is the incidence of fungal infections has increased globally in the last few decades. Fungal periprosthetic infections, although rare, are similarly increasing in prevalence. Most case series of patients with fungal periprosthetic joint infections report a disastrous outcome for surgical management of these patients with treatment failure rates of up to 50% at 2-year follow-up. Part of the problem relates to the complex biofilm that fungi can form. Furthermore, patients with fungal periprosthetic joint infection are often immunocompromised with impaired cellular immunity.
We feel the importance of host factors is often overlooked in the preoperative assessment of patients with periprosthetic joint infection (PJI), particularly those PJIs caused by fungi. Data from our institution suggest 76% of patients with fungal PJI have one or more systemic conditions known to be associated with immune system suppression. Furthermore, several intrinsic and extrinsic host risk factors are known to be associated with fungal PJI. Intrinsic host risk factors include immunodeficiency, neutropenia, malnutrition, prior organ transplantation, malignancy, renal dialysis and prior Candida colonization. External factors, such as the presence of an indwelling IV catheter, parenteral nutrition lines, chronic antibiotic use, prior bacterial PJI, severe burns, IV drug abuse or immunomodulatory medications (eg, corticosteroids, monoclonals and antineoplastic agents) may also contribute to the problem. These factors must be considered to help determine the risk for fungal PJI occurrence at an early stage in a patient’s treatment journey. By doing so, one can establish the need for local and systemic antifungal therapy within the preoperative phase, for instance with prior aspiration and prolonged fungal culture. This may also avoid inadequate antifungal coverage within spacers, as well as any surprises at the time of final fungal culture reporting (typically at 7 days to 14 days postoperatively).
Current fungal PJI treatment guidelines from the Infectious Diseases Society of America (IDSA) and International Consensus Meeting on Periprosthetic Joint Infection (ICM) both recommend a two-stage exchange arthroplasty, with some evidence for inclusion of an antifungal (liposomal amphotericin B or voriconazole) plus an antibacterial agent within the cement spacer. However, although IDSA guidelines advise a minimum of 3 months of systemic antifungal use following resection arthroplasty, the ICM suggested this therapy need only be continued for 6 weeks. It is also important to note that IDSA guidelines on the treatment of candidiasis recommend that there is a longer antifungal treatment duration of 6 months to 12 months for osteomyelitis.
To conclude, until molecular diagnostic methods for pathogen identification are able to provide rapid point-of-care results, we suggest the pragmatic approach of stratifying patients based on their immunosuppressive risk factors to generate an appropriate index of suspicion for fungal PJI. Second, we wish to reiterate the IDSA guidelines that advocate prolonged systemic antifungal therapy after resection arthroplasty. Perhaps awareness of these two factors will assist in the recognition and treatment of these devastating infections. The adage of Benjamin Franklin certainly holds true here: “By failing to prepare, you are preparing to fail.”
- References:
- Azzam K, et al. J Bone Joint Surg Am. 2009;doi:10.2106/JBJS.I.00574.
- Gebauer M, et al. J Arthroplasty. 2014;doi:10.1016/j.arth.2013.09.049.
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- Martin GS, et al. N Engl J Med. 2003; doi:10.1056/NEJMoa022139.
- Pappas PG, et al. Clin Infect Dis. 2016;doi:10.1093/cid/civ933.
- For more information:
- Karan Goswami, MD; Feng-Chih Kuo, MD; and Javad Parvizi, MD, FRCS; can be reached at Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 S. 9th St., Philadelphia, PA 19107. Goswami’s email: karan.goswami@mail.com; Kuo’s email: feng.kuo@rothmaninstitute.com; Parvizi’s email: parvj@aol.com.
Disclosures: Parvizi reports he is a paid consultant for Zimmer Biomet, ConvaTec, TissueGene, CeramTec and Ethicon; has stock options with Parvizi Surgical Innovations, Hip Innovation Technology, CD Diagnostics, CorenTec, Alphaeon, Joint Purification Systems, Ceribell, MedAp, MicroGenDx, Cross Current Business Intelligence, Invisible Sentinel, Physician Recommended Nutriceuticals and Intellijoint; and receives royalties from CorenTec, Datatrace, Elsevier, Jaypee, SLACK Incorporated and Wolters Kluwer. Goswami and Kuo report no relevant financial disclosures.