Fluconazole-impregnated beads in the management of fungal infection of prosthetic joints

Osteoarticular Mycoses

Osteoarticular mycoses are chronic debilitating infections that require extended courses of antifungal therapy and may warrant expert surgical intervention. As there has been no comprehensive review of these diseases, the International Consortium for Osteoarticular Mycoses prepared a definitive treatise for this important class of infections. Among the etiologies of osteoarticular mycoses are Candida spp., Aspergillus spp., Mucorales, dematiaceous fungi, non-Aspergillus hyaline molds, and endemic mycoses, including those caused by Histoplasma capsulatum, Blastomyces dermatitidis, and Coccidioides species. This review analyzes the history, epidemiology, pathogenesis, clinical manifestations, diagnostic approaches, inflammatory biomarkers, diagnostic imaging modalities, treatments, and outcomes of osteomyelitis and septic arthritis caused by these organisms. Candida osteomyelitis and Candida arthritis are associated with greater events of hematogenous dissemination than those of most other osteoarticular mycoses. Traumatic inoculation is more commonly associated with osteoarticular mycoses caused by Aspergillus and non-Aspergillus molds. Synovial fluid cultures are highly sensitive in the detection of Candida and Aspergillus arthritis. Relapsed infection, particularly in Candida arthritis, may develop in relation to an inadequate duration of therapy. Overall mortality reflects survival from disseminated infection and underlying host factors.

Candida Periprosthetic Joint Infection: Is It Curable?

Candida periprosthetic joint infection (CPJI) is a rare and very difficult to treat infection, and high-quality evidence regarding the best management is scarce. Candida spp. adhere to medical devices and grow forming biofilms, which contribute to the persistence and relapse of this infection. Typically, CPJI presents as a chronic infection in a patient with multiple previous surgeries and long courses of antibiotic therapy. In a retrospective series of cases, the surgical approach with higher rates of success consists of a two-stage exchange surgery, but the best antifungal treatment and duration of antifungal treatment are still unclear, and the efficacy of using an antifungal agent-loaded cement spacer is still controversial. Until more evidence is available, focusing on prevention and identifying patients at risk of CPJI seems more than reasonable.

Efficacy of antifungal-impregnated cement spacer against chronic fungal periprosthetic joint infections after total knee arthroplasty

BACKGROUND

Although two-stage exchange arthroplasty is considered a treatment of choice for chronic features of fungal PJI (periprosthetic joint infection), there is no consensus for local use of antifungal agent. The purpose of this study was to evaluate the efficacy of antifungal-impregnated cement spacer (AICS).

METHODS

Nine patients who were diagnosed and treated for chronic fungal PJI after TKA in a single center from January 2001 to December 2016 were enrolled. Two-stage exchange arthroplasty was performed. During the 1st stage resection arthroplasty, AICS was inserted for all patients. Systemic antifungal medication was used during the interval between the two stage operations.

RESULTS

The average duration from the initial symptom to fungal PJI diagnosis was 20 months (range, five to 72 months). Average erythrocyte sedimentation rate and C-reactive protein level at diagnosis were 56 mm/h (range, 30 to 89 mm/h) and 2.25 mg/dl (range, 0.11 to 3.97 mg/dl), respectively. Fungal PJI was confirmed by open debridement tissue culture in three cases (33%). The average number of operations before final exchange arthroplasty was 2.7 times (range, one to five times). Average duration of antifungal agent use confirmed by sensitivity test was seven months (range, four to 15 months). Mean interval between the two stage operations was six months (range, 1.5 to 15 months). After two-stage exchange arthroplasty, no patient had recurrent fungal infection during a mean follow-up of 66 months (range, 24 to 144 months).

CONCLUSION

Two-stage exchange arthroplasty with AICS is a very effective strategy with excellent outcomes.

LEVEL OF EVIDENCE

Case series, IV.

Candida Prosthetic Joint Infection. A Review of Treatment Methods

Fungal microorganisms are still a rare cause of bone and joint infections. We report a new case of knee prosthetic joint infection due to Candida albicans in a patient with a previous two-stage right knee arthroplasty for septic arthritis due to S. epidermidis occurred several months ago. Moreover, the treatment in 76 cases of Candida prosthetic joint infection has been discussed. Forty patients were female and mean age at diagnosis was 65.7 (± SD 18) yrs. No risk factors for candidal infection were found in 25 patients. Infection site was the knee in 38 patients and hip in 36; pain was present in 44 patients and swelling in 24. The most frequent species was C. albicans, followed by C. parapsilosis. Eleven patients were only treated with antifungal drugs being the outcome favourable in all of them. Two-stage exchange arthroplasty was performed in 30 patients, and resection arthroplasty in other 30; in three patients one-stage exchange arthroplasty was done. A favourable outcome was found in 58 patients after antifungal plus surgical treatment, in 11 after antifungal treatment alone and in one after surgery alone. The type of treatment is still not clearly defined and an algorithm for treatment in fungal PJI should be established, but various types of surgical procedures may be applied.

Systemic review of published literature on Candida infection following total hip arthroplasty

Candida species (Candida spp.) infection following total hip arthroplasty (THA) is a rare but potentially devastating complication. The purpose of this study was to provide an evidence-based summarization of the treatment and outcome of Candida spp. infection after THA. We conducted a systemic review of the literature and pooled analysis of Candida spp. infection after THA published between 1950 and 2014. A total of 20 articles with 37 patients were identified. Median time between THA and readmission for Candida spp. infection was 25 months (range 0.5-184 months). Thirty-two patients (87%) underwent removal of the prosthesis for initial surgical treatment. All patients were treated with systemic antifungal medication therapy for various durations after the surgical procedure or primary therapy without surgical procedures except for one patient who was treated with only amphotericin B joint cavity irrigation after removal of the prosthesis. Relapse of the infection occurred in three patients who had retention of the original prosthesis. There were three deaths related to the Candida spp. infection following THA owing to uncontrolled Candida spp. infection and deteriorating candidemia sepsis. Of note, among 15 patients who underwent two-stage exchange arthroplasty, there was one patient (7%) who developed complication (death) while other 14 patients had uncomplicated recovery. In conclusion, surgical debridement with removal of the original prosthesis or two-stage exchange arthroplasty with combination of adequate systemic antifungal therapy is highly recommended in the treatment of Candida spp. infection following THA.

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.

Periprosthetic joint infections: clinical and bench research

Prosthetic joint infection is a devastating complication with high morbidity and substantial cost. The incidence is low but probably underestimated. Despite a significant basic and clinical research in this field, many questions concerning the definition of prosthetic infection as well the diagnosis and the management of these infections remained unanswered. We review the current literature about the new diagnostic methods, the management and the prevention of prosthetic joint infections.

Coccidioidomycosis infection of a total knee arthroplasty in a nonendemic region

Fungal prosthetic joint infections are rare and difficult to treat. There is an ongoing discussion about the type and duration of antifungal treatment and the necessity of prosthesis removal. We report the first European case of an infected total knee arthroplasty with Coccidioides immitis. Treatment consisted of lifelong treatment with oral fluconazole at a dose of 400 mg/d, without total knee arthroplasty removal. After 6 months, the initial complaints of pain and swelling were completely resolved. This case report clearly states that a travel history and culturing for fungi are helpful in patients with persisting complaints after joint arthroplasty.

Fungal periprosthetic hip and knee joint infections clinical experience with a 2-stage treatment protocol

Fungal periprosthetic joint infections are a rare entity in orthopedic surgery, and there exist no guidelines according to which these infections can be successfully managed. Between 2004 and 2009, 7 patients with fungal periprosthetic joint infections (4 total hip arthroplasties and 3 total knee arthroplasties) have been treated with a 2-stage protocol and implantation of antibiotic-loaded cement spacers. Most of the infection was caused by Candida species. Systemic antifungal agents were administered for 6 weeks in 6 cases and 6 months in 1 case. The mean spacer implantation time was 12 weeks. At a mean follow-up of 28 months (5-70 months), no persistence of infection or reinfection could be observed. A 2-stage treatment protocol with implantation of an antibiotic-loaded cement spacer is an efficient option in the treatment of fungal periprosthetic infections.

Are anidulafungin or voriconazole released from polymethylmethacrylate in vitro?

BACKGROUND

Depot delivery of antimicrobial agents is used for treatment and prevention of bacterial orthopaedic infections; there is little information regarding newer antifungal agents and their potential use in polymethylmethacrylate (PMMA) depot delivery.

QUESTIONS/PURPOSES

We determined the percent of anidulafungin or voriconazole present after polymerization in PMMA beads loaded with anidulafungin or voriconazole, and we assessed elution of anidulafungin or voriconazole from beads loaded with anidulafungin or voriconazole.

MATERIALS AND METHODS

Beads containing 7.5% anidulafungin or voriconazole were pulverized and incubated in Kreb's ringer buffer for 48 hours; the buffer was assayed for anidulafungin or voriconazole concentration. The in vitro release of anidulafungin and voriconazole from PMMA beads loaded with 7.5% anidulafungin or voriconazole was determined in triplicate in a continuous flow chamber.

RESULTS

0.7% of anidulafungin and 5.6% of voriconazole loaded in the beads were detected after polymerization. No anidulafungin was detected in the elution studies. The mean peak voriconazole concentration in the elution studies was 0.9 μg/mL.

CONCLUSIONS

Anidulafungin may not be suitable for depot delivery in PMMA.

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.

Our current understanding of fungal biofilms

Fungal biofilms are an escalating clinical problem associated with significant rates of mortality. Candida albicans is the most notorious of all fungal biofilm formers. However, non-Candida species, yeasts such as Cryptococcus neoformans, and filamentous moulds such as Aspergillus fumigatus, have been shown to be implicated in biofilm-associated infections. Fungal biofilms have distinct developmental phases, including adhesion, colonisation, maturation and dispersal, which are governed by complex molecular events. Recalcitrance to antifungal therapy remains the greatest threat to patients with fungal biofilms. This review discusses our current understanding of the basic biology and clinical implications associated with fungal biofilms.

Delivery of Antifungal Agents Using Bioactive and Nonbioactive Bone Cements

Background:

Management of fungal osteomyelitis is prolonged and frequently unsuccessful. Antifungal-impregnated cement is sometimes used as adjunctive therapy.

Objective:

To examine the release of antifungals from biodegradable and nonbiodegradable cement carriers.

Methods:

In vitro methods were used to assess antifungal drug release and antifungal activity of impregnated cements commonly used as adjunctive treatment of osteomyelitis. Cements included thermoplastic, nonbioactive polymers (polymethylmethacrylate [PMMA]) or bioactive agents (hydroxyapatite [HAP], β-tricalcium phosphate [β-TCP]) and were formed into spheres (beads).

Results:

Amphotericin B provided consistent supernatant concentrations (release), between 1.75 and 2.0 ug/mL, over 110 days from all bone cements. Flucytosine and fluconazole were observed for 33–42 days before becoming undetectable from a nonbioactive sphere and 18–22 days from a bioactive sphere. Serum concentrations for micafungin, terbinafine, and anidulafungin impregnated into PMMA rapidly became undetectable, regardless of the matrix used. Investigational β-TCP spheres prolonged release for fluconazole and micafungin, but had no effect on amphotericin B. Serum calcium concentrations decreased 60–80% in all HAP-impregnated drug sphere supernatants. Only amphotericin B–impregnated PMMA impacted supernatant calcium, decreasing concentrations by 50–60%. The antifungal-impregnated beads did not appear to be toxic to osteoblasts during 72 hours of exposure in tissue culture medium.

Conclusions:

Elution characteristics of most antifungals from bone cement spheres are probably not optima) for treatment of deep-seated fungal infections if a similar phenomenon of antifungal release manifests in vivo. Ceramic nonabsorbable impregnated devices must be removed after their lifespan expires and may necessitate another surgical procedure that can increase surgical risk and cost. Bioactive osteoconductive materials may provide a surgical alternative to nonabsorbable matrices. However, there have been no controlled trials demonstrating improved therapeutic outcomes with local therapy and assessing whether biodegradable materials act as a new focus for infection.