title: What is the success of treatment of hip and knee candidal periprosthetic joint infection?
abstract: BACKGROUND
  Fungal infection at an arthroplasty site is rare and poses a therapeutic challenge. To the best of our knowledge, no reports have been published thus far on the success rate of prosthesis reimplantation after fungal prosthetic joint infections.
  
  
  OBJECTIVE
  We asked: (1) What is the success rate in terms of infection eradication using a two-stage exchange arthroplasty in patients with hip or knee fungal periprosthetic joint infections, particularly focusing on Candida infections? (2) What patient-, infection-, and treatment-related variables are associated with the success or failure of treatment?
  
  
  METHODS
  From January 2000 to December 2010, 16 patients with hip or knee candidal periprosthetic joint infections were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined as a well-functioning joint without relapse of candidal infection after prosthesis reimplantation, while treatment failure was defined as uncontrolled or relapse of candidal infection or mortality. Variables, including age, sex, comorbidities, microbiology, antimicrobial agents used, and operative methods, were analyzed. Minimum followup was 28 months (mean, 41 months; range, 28-90 months).
  
  
  RESULTS
  At latest followup, the treatment failed to eradicate the infection in eight of the 16 patients, and there were four deaths related to fungemia. Four patients required permanent resection arthroplasty owing to uncontrolled or recurrent candidal infections. All eight patients (50% successful rate) who had their infections eradicated and successful prosthesis reimplantation had prolonged treatment with oral fluconazole before (mean, 8 months) and after (mean, 2.2 months) prosthesis reimplantation. The antifungal therapy correlated with successful treatment. Renal insufficiency, hypoalbuminemia, anemia, and chronic obstructive pulmonary disease were significantly more prevalent in the treatment-failure group than in the treatment-success group.
  
  
  CONCLUSIONS
  Half of the patients treated with two-stage exchange arthroplasty for fungal periprosthetic joint infections had recurrence or lack of control of the infection. A prolonged antifungal therapy appeared to be essential for successful treatment of candidal periprosthetic joint infections. The presence of renal insufficiency, hypoalbuminemia, anemia, or chronic obstructive pulmonary disease might be associated with a poor outcome.
authors: Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St, Kweishan, Linkou, 333, Taiwan.
authors: Steve W N
authors: SW
authors: Ueng
authors: Ching-Yu
authors: CY
authors: Lee
authors: Chih-chien
authors: CC
authors: Hu
authors: Pang-Hsin
authors: PH
authors: Hsieh
authors: Yuhan
authors: Y
authors: Chang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000935:Antifungal Agents / Q000627:therapeutic use; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D002177:Candidiasis / Q000188:drug therapy / Q000601:surgery*; D003131:Combined Modality Therapy; D003646:Debridement; D005260:Female; D006622:Hip Prosthesis / Q000382:microbiology*; D006801:Humans; D007719:Knee Joint / Q000382:microbiology / Q000601:surgery; D007720:Knee Prosthesis / Q000382:microbiology*; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents
references: J Arthroplasty. 1998 Sep;13(6):707-12
references: 9741450
references: Clin Infect Dis. 2009 Mar 1;48(5):503-35
references: 19191635
references: J Arthroplasty. 2003 Sep;18(6):813-5
references: 14513461
references: J Infect. 2001 Apr;42(3):208-9
references: 11545555
references: J Bone Joint Surg Am. 1996 Apr;78(4):512-23
references: 8609130
references: J Arthroplasty. 2012 Feb;27(2):293-8
references: 21752583
references: J Arthroplasty. 1997 Dec;12(8):950
references: 9458262
references: J Arthroplasty. 2007 Sep;22(6):902-8
references: 17826283
references: J Bone Joint Surg Am. 1989 Jun;71(5):669-78
references: 2732255
references: Clin Infect Dis. 1996 Nov;23(5):964-72
references: 8922787
references: Knee Surg Sports Traumatol Arthrosc. 2011 Feb;19(2):273-6
references: 20652534
references: J Bone Joint Surg Am. 2011 Aug 3;93(15):1448-54
references: 21915551
references: J Hosp Infect. 2005 Oct;61(2):146-54
references: 16009456
references: J Bone Joint Surg Am. 2007 Apr;89(4):871-82
references: 17403814
references: Chirurg. 2001 Nov;72(11):1336-43
references: 11766659
references: Clin Infect Dis. 2002 Apr 1;34(7):930-8
references: 11880958
references: J Bone Joint Surg Am. 1987 Sep;69(7):1013-21
references: 3654692
references: J Bone Joint Surg Am. 1990 Feb;72(2):272-8
references: 2303514
references: Acta Orthop Scand. 1997 Jun;68(3):306-7
references: 9247001
references: Clin Orthop Relat Res. 2008 Jul;466(7):1710-5
references: 18421542
references: Clin Microbiol Rev. 2008 Oct;21(4):606-25
references: 18854483
references: J Arthroplasty. 1997 Oct;12(7):825-9
references: 9355014
references: Orthopedics. 2002 Dec;25(12):1391-4; discussion 1394
references: 12502204
references: J Rheumatol. 1979 Jul-Aug;6(4):451-5
references: 392095
references: Clin Pharmacokinet. 1993 Jan;24(1):10-27
references: 8448970
references: Clin Orthop Relat Res. 1988 Jan;(226):235-9
references: 3275513
references: J Bone Joint Surg Am. 1990 Dec;72(10):1551-3
references: 2254366
references: J Knee Surg. 2010 Sep;23(3):169-74
references: 21329258
references: J Bone Joint Surg Am. 2009 Nov;91 Suppl 6:142-9
references: 19884422
references: J Bone Joint Surg Br. 2006 Feb;88(2):149-55
references: 16434514
references: J Bone Joint Surg Am. 2007 Jun;89(6):1227-31
references: 17545425
references: Clin Infect Dis. 1995 Apr;20(4):1068-9
references: 7795057
references: J Bone Joint Surg Am. 1983 Oct;65(8):1087-98
references: 6630253
references: Clin Infect Dis. 2000 Apr;30(4):688-95
references: 10770731
references: Antimicrob Agents Chemother. 1989 Sep;33(9):1443-6
references: 2554797
references: J Arthroplasty. 2004 Oct;19(7):927-30
references: 15483812
references: J Bone Joint Surg Am. 2004 Feb;86(2):335-41
references: 14960679
references: J Arthroplasty. 2009 Sep;24(6 Suppl):84-8
references: 19604665
references: J Bone Joint Surg Am. 1984 Jan;66(1):142-3
references: 6690437