Periprosthetic fungal infections : be alert clinical cases and review of the literature

Abstract

The increasing rate of arthroplasty, revisions and resistance to antibiotics has increased the risk for fungal infections. Different treatment modalities exist: suppressive therapy, debridement with retained prosthesis, Girdlestone procedures and 2- or even 3-stage revision arthroplasty. Fungal infections after joint replacements are rare but devastating. PURPOSE OF THE STUDY : The aim was to see if there was any trend that could help with the diagnosis and management of patients with fungal infections. The literature was reviewed in order to assist with diagnosis and treatment. MATERIALS AND METHODS : A retrospective study was performed and all the cases seen and treated by a tumour and sepsis orthopaedic specialist from 1999 to 2015 were evaluated. Inclusion criteria: Patients had to be diagnosed with a fungal infection in any specimen which was sent for histology or culture. Exclusions: none. RESULTS : Four patients were identified. All of them were males. Mean age 58 (35–71) years. The primary surgical indications were: vertebral osteomyelitis; post primary knee replacement; pig bite with lower limb sepsis and osteoarthritis knee, and a septic total hip replacement. Three cases cultured Candida parapsilosis and one Candida albicans of which three were tissue cultures and one a blood culture. Currently 75% have failed treatment – one passed away, one developed systemic sepsis, and one had an above-knee amputation and is still struggling with subsequent bacterial infections in the amputation stump. CONCLUSION : As long as there are higher incidences of fungal infections with devastating complications more evidence is needed. Numerous small case studies have been published, with the purpose of looking for the correct treatment: monotherapy, combination therapy, newer antifungals, higher dosages, implant retention or removal. It appears that the correct answer is unclear as yet. It is important to always have a high index of suspicion and good pre-operative planning together with a team approach: infectious diseases specialist, microbiologist and histologist. This approach will optimise the probability of making a diagnosis and to appropriately manage the fungus cultured.