Risk Factors for Fungal Prosthetic Joint Infection.

Talha Riaz,Lisa L Steed,Camelia E Marculescu,Douglas R Osmon,Harry A Demos,Aaron J Tande,Cassandra D Salgado

doi:10.7150/jbji.40402

Abstract

Background: Fungal prosthetic joint infections (PJIs) are rare and often associated with poor outcome; however, risk factors are not well described.Methods: This was a retrospective case control study among all patients with PJIs from 2006-2016 at two major academic centers. Each fungal PJI case was matched 1:1 with a bacterial PJI control by joint (hip, knee, shoulder) and year of diagnosis. We compared demographics, comorbidities, and clinical characteristics between cases and controls using chi square/Fisher's exact or Wilcoxon rank sum test. Independent risk factors were identified with multivariable logistic regression.Results: Forty-one fungal PJIs occurred over the study and 61% were due to Candida albicans. The hip was involved in 51.2% of cases, followed by the knee (46.3%). Compared to bacterial PJI, fungal PJI cases were more likely to have received antibiotics within the previous 3 months (70.7% vs 34%, P=.001), wound drainage lasting >5 days (48% vs 9%, P=.0002), had a lower median CRP (2.95 mg/dl vs 5.99, P=.013) and synovial fluid white blood cell count (13,953 cells/mm3 vs 33,198, P=.007), and a higher proportion of prior two-stage exchanges (82.9% vs 53.6%, P=.008). After controlling for center, prolonged wound drainage (OR, 7.3; 95% CI, 2.02-26.95) and recent antibiotics (OR, 3.4; 95% CI, 1.2-9.3) were significantly associated with fungal PJI.Conclusion: In our study, Candida albicans was the most common species in fungal PJIs and prolonged wound drainage and recent antibiotics were independent risk factors. These clinical characteristics may help providers anticipate fungal PJI and adjust management strategies.

Highlights

The number of patients living with implanted joint prostheses continues to increase
Our data suggest that there are two factors significantly associated with an increased odds of fungal prosthetic joint infection (PJI) when compared with bacterial PJIs; antimicrobial therapy within three months before the diagnosis of PJI was associated with a 3.4-fold increased odds of having a fungal PJI, and presence of wound drainage lasting longer than five days prior to the diagnosis of PJI was associated with a 7.3-fold increased odds of fungal PJI
We found that receipt of antibiotics in the previous 90 days had a significant association with acquisition of fungal PJI

Summary

Introduction

The number of patients living with implanted joint prostheses continues to increase. Many of these patients are older and require revision of the joint prosthesis due to polyethylene wear or aseptic loosening [1]. Just as for other foreign devices, prosthetic joint infection (PJI) is a well-documented adverse outcome. PJI is among the main reasons for failure of joint arthroplasty [2], causing significant morbidity and mortality [3, 4]. Treatment requires removal of the infected prosthesis and several weeks of intravenous antibiotics, followed by revision surgery, with an estimated cost of more than $50,000 for each episode of infection [5]. The most commonly implanted joints are knee and hip prosthesis, followed by shoulder arthroplasties. Fungal prosthetic joint infections (PJIs) are rare and often associated with poor outcome; risk factors are not well described

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Results

Discussion

Conclusion