Fungal periprosthetic infection is associated with a poor outcome

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Authors: Bracken CD, Berbari EF, Hanssen AD, Mabry TM, Osmon DR, Sierra RJ.
Mayo Clinic, Rochester, MN

Title: Fungal periprosthetic infection is associated with a poor outcome

Background: Fungal Periprosthetic Joint Infections (F-Pjis) are Rare.  The Results of Surgical Management And Clinical Outcomes Of Patients with F-PJI Have Not Been Fully Assessed.

Hypothesis/Purpose: What are the demographics and outcomes of patients with F-PJI managed with different surgical strategies?

Methods: 43 patients with F-PJIs treated at our institution between 1/1/2002 and 12/31/2011 and followed for at least 18 months were enrolled in this study.  The mean time from index arthroplasty to F-PJI diagnosis or resection was 4.5 years (range:  30 days to 27 years).  The mean age was 68 years and 47% of the episodes occurred in females.  There was equal distribution between TKA and THA.  73% of cultures were fungal only while the rest were mixed (bacterial/fungal).  Candida albicans was the fungal organism in 52% of cases.  33 of 43 (77%) had experienced prior episodes of bacterial PJIs.  Consequently, 40% of the joints were resected previously (mean time from resection to fungal infections was 153 days).  Patients were followed until death, joint failure, latest or loss of follow-up.

Results: The mean follow-up from surgery was 30 months (range:  1 to 10 years).  The average number of surgical procedures to treat F-PJI was 3 (range:  1 to 7).  Of the 43 F-PJIs, 16 (37%) underwent a 2-stage surgery, 16 (37%) underwent permanent resection, 6 (14%) underwent amputation, and 2 (5%) required arthrodesis.  In addition, 2 (5%) underwent I and D with retention of components and one was aspirated and suppressed with antifungal therapy.  Following therapy, 16 had failure of treatment with persistent infection (5 of 22 knees and 11 of 21 hips). The 5 year cumulative incidence free of recurrence of PJI in patients treated with 2-stage surgery was 63% for knees and 53% for hips.

Discussion: Only a third of patients were considered candidates for two stage surgery and within this group, only 61% had a successful outcome.  Despite undergoing permanent resection, 10 of 16 (63%) patients still had evidence of joint involvement and were on chronic suppression.  The rest of the patients were treated with amputation, arthrodesis, or I and D and were infection free at last follow-up.  Due to poor outcomes with F-PJI, a better understanding of risk factors and novel management strategies may be warranted.

Conclusion: The outcome of patients with F-PJI is poor. Only one third of patients are candidates for reimplantation, and only half of those are free of infection at 5 years.