Microbiological, Clinical, and Surgical Features of Fungal Prosthetic Joint Infections: A Multi-Institutional Experience

Abstract

Periprosthetic joint infection is one of the most dreaded and complex complications of total joint arthroplasty. Periprosthetic joint infection is now the major cause of failure following total knee arthroplasty1 and the third most common cause of failure following total hip arthroplasty2. It is estimated that the prevalence of periprosthetic joint infection may be on the rise3. A wide variety of pathogens are known to cause periprosthetic joint infection, with the majority of infections being caused by gram-positive bacteria, especially staphylococcal species4,5. The treatment of a confirmed periprosthetic joint infection often includes the need for surgical intervention, and two-stage exchange arthroplasty is the most common mode of surgical treatment in North America. Two-stage exchange arthroplasty relies on removal of all foreign material and insertion of an antibiotic-impregnated cement spacer for the purpose of delivering high doses of antibiotics locally in the interval of time between the resection arthroplasty and subsequent reimplantation. Periprosthetic infection with fungi, although rare, represents a diagnostic and therapeutic challenge to which clear guidelines have not yet been established. It is not known if the protocol for treatment of a bacterial periprosthetic joint infection can also be applied in the same manner to fungal infections. Patients with fungal periprosthetic joint infection are believed to be a different type of host with decreased cellular immunity, mostly due to an underlying cause of immunosuppression, such as malignant disease, drug therapies (antineoplastic agents, corticosteroids, or immunosuppressive drugs), overuse or inappropriate use of antibiotics, and indwelling catheters (urinary or parenteral hyperalimentation). Other factors, such as diabetes, tuberculosis, intravenous drug use, and acquired immunosuppressive disease, are associated with an increased frequency of mycotic infection6. The lack of reliable antifungal medications for systemic and, in particular, local delivery poses a real challenge …