title: 2-stage revision recommended for treatment of fungal hip and knee prosthetic joint infections.
abstract: OBJECTIVE
  Fungal prosthetic joint infections are rare and difficult to treat. This systematic review was conducted to determine outcome and to give treatment recommendations.
  
  
  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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopedic Surgery , Center for Orthopaedic Research Alkmaar (CORAL), Alkmaar Medical Center, Alkmaar ; the Netherlands.
authors.forename: Jesse W P
authors.initials: JW
authors.lastname: Kuiper
authors.forename: Michel P J
authors.initials: MP
authors.lastname: van den Bekerom
authors.forename: Jurgen
authors.initials: J
authors.lastname: van der Stappen
authors.forename: Peter A
authors.initials: PA
authors.lastname: Nolte
authors.forename: Sascha
authors.initials: S
authors.lastname: Colen
mesh_terms: D000935:Antifungal Agents / Q000627:therapeutic use; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D003131:Combined Modality Therapy; D006622:Hip Prosthesis / Q000009:adverse effects*; D006801:Humans; D007720:Knee Prosthesis / Q000009:adverse effects*; D009181:Mycoses / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D012086:Reoperation / Q000379:methods; D012307:Risk Factors
chemical_list: D000935:Antifungal Agents