title: Successful treatment of Candida osteoarticular infections with limited duration of antifungal therapy and orthopedic surgical intervention.
abstract: BACKGROUND
  Current guidelines for treatment of Candida osteoarticular infections (COAIs) recommend a prolonged course of antifungal therapy (AFT) of 6-12 months. Based upon strategies developed at the Hospital for Special Surgery (HSS), we hypothesized that the duration of antifungal therapy may be substantially reduced for management of COAI.
  
  
  METHODS
  This was a retrospective chart review of cases of COAI treated at the HSS for the past 14 years. COAI was documented by open biopsy and direct culture in all cases. The mean (95% confidence interval, CI) duration of documented follow-up was 39 (16-61) months.
  
  
  RESULTS
  Among the 23 cases of COAI, the median age was 62 years (range 22-83 years) with 61% having no underlying condition. Orthopedic appliances, including joint prostheses and fracture hardware, were present in 74% of cases. All patients had COAI as the first proven site of candidiasis. Candida albicans and Candida parapsilosis were the most common species. Hip, knee, foot, and ankle were the most common sites. All patients received aggressive surgical intervention followed by AFT administered for a mean (95% CI) duration of 45 (38-83) days. Systemic AFT consisted principally of fluconazole alone (65%) or in combination with other agents (26%). Adjunctive intraoperative amphotericin B irrigation was used in 35%. Among eight cases of CAOI that required placement of a new prosthetic joint, all were successfully treated. There were no microbiologic failures.
  
  
  CONCLUSIONS
  Candida osteoarticular infections may be successfully treated with substantially limited durations of AFT when combined with a thorough surgical approach.
authors.affiliation: From the Division of Infectious Diseases, Department of Medicine, Weill Cornell Medical Center , New York.
authors.forename: Andy O
authors.initials: AO
authors.lastname: Miller
authors.forename: Maria N
authors.initials: MN
authors.lastname: Gamaletsou
authors.forename: Michael W
authors.initials: MW
authors.lastname: Henry
authors.forename: Leen
authors.initials: L
authors.lastname: Al-Hafez
authors.forename: Kaiser
authors.initials: K
authors.lastname: Hussain
authors.forename: Nikolaos V
authors.initials: NV
authors.lastname: Sipsas
authors.forename: Dimitrios P
authors.initials: DP
authors.lastname: Kontoyiannis
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Roilides
authors.forename: Barry D
authors.initials: BD
authors.lastname: Brause
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Walsh
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000666:Amphotericin B / Q000008:administration & dosage / Q000627:therapeutic use*; D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D002175:Candida / Q000302:isolation & purification* / Q000472:pathogenicity; D002176:Candida albicans / Q000302:isolation & purification; D002177:Candidiasis / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery / Q000628:therapy*; D003131:Combined Modality Therapy; D003840:Deoxycholic Acid / Q000008:administration & dosage / Q000627:therapeutic use*; D004338:Drug Combinations; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D010019:Osteomyelitis / Q000188:drug therapy / Q000382:microbiology / Q000601:surgery / Q000628:therapy*; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D000935:Antifungal Agents; D004338:Drug Combinations; D003840:Deoxycholic Acid; D000666:Amphotericin B; C059765:amphotericin B, deoxycholate drug combination
keywords: Candida spp.; antifungal therapy; joint prosthesis; osteoarticular infections