[Candida infection in hip alloarthroplasty]

Trichosporon asahii infection after total knee arthroplasty: A case report and review of the literature

Reports of fungal infection after total knee arthroplasty are extremely rare. In most reports, the infecting organism is a Candida species. The present report describes a case involving a 73-year-old immunocompetent woman who underwent total knee arthroplasty and presented one month later with signs of prosthetic infection. She underwent joint debridement and the fluid was sent for culture and sensitivity testing. The culture showed growth of Trichosporon asahii. The patient was administered intravenous and intra-articular injections of amphotericin B, followed by antifungal treatment with voriconazole for one year. At 26 months of follow-up, there was no evidence of infection and the patient was ambulating with a walker. To the authors' knowledge, the present case is the first report of T asahii infection following knee replacement. Early detection, prompt institution of the appropriate antibiotics and regular follow-up are recommended.

2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections

BACKGROUND AND PURPOSE

Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations.

PATIENTS AND METHODS

After an extensive search of the literature, 164 patients treated for fungal hip or knee prosthetic joint infection (PJI) were reviewed. This included 8 patients from our own institutions.

RESULTS

Most patients presented with pain (78%) and swelling (65%). In 68% of the patients, 1 or more risk factors for fungal PJI were found. In 51% of the patients, radiographs showed signs of loosening of the arthroplasty. Candida species were cultured from most patients (88%). In 21% of all patients, fungal culture results were first considered to be contamination. There was co-infection with bacteria in 33% of the patients. For outcome analysis, 119 patients had an adequate follow-up of at least 2 years. Staged revision was the treatment performed most often, with the highest success rate (85%).

INTERPRETATION

Fungal PJI resembles chronic bacterial PJI. For diagnosis, multiple samples and prolonged culturing are essential. Fungal species should be considered to be pathogens. Co-infection with bacteria should be treated with additional antibacterial agents. We found no evidence that 1-stage revision, debridement, antibiotics, irrigation, and retention (DAIR) or antifungal therapy without surgical treatment adequately controls fungal PJI. Thus, staged revision should be the standard treatment for fungal PJI. After resection of the prosthesis, we recommend systemic antifungal treatment for at least 6 weeks-and until there are no clinical signs of infection and blood infection markers have normalized. Then reimplantation can be performed.

Candida glabrata: an unusual fungal infection following a total hip replacement

A 60-year-old woman, after a femoral neck fracture and joint replacement, underwent a Girdlestone's procedure and received aggressive antimicrobial therapy in order to completely eradicate the fungal infection Candida glabrata. In the majority of such cases, a revised hip arthroplasty would be considered following debridement. However, due to the recurrence of this infection and a key associated risk factor, radical removal with concurrent drug therapy was the only option.

Candida prosthetic infections: case series and literature review

Candida prosthetic joint infections are considered to be rare. We retrospectively studied patients treated for Candida prosthetic infections between 1 January 1995 and 31 December 2007 in our infectious diseases department, a tertiary referral centre. We identified 7 patients, 4 with knee and 3 with hip prosthetic infections. The most frequent fungal agent was Candida albicans (4 cases), followed by Candida parapsilosis (2 cases) and Candida guillermondii (1 case). All the patients received antifungal treatment for a prolonged period. Five patients had their prosthesis removed and 3 had reimplantation, 1 patient was treated with debridement and prosthetic retention, and the last patient refused surgery. The mean follow-up time was 2.5 y. At the last evaluation, 3 patients were considered as cured, 3 patients presented a secondary bacterial infection leading to amputation for 2 of them, and 1 patient died from heart failure. During Candida prosthetic joint infections, the epidemiological characteristics and the location of the prosthesis are very similar to bacterial prosthetic infections. The benchmark antifungal therapies remain amphotericin B and/or fluconazole.