Diagnosis and Management of Fungal Periprosthetic Joint Infections

James Nace, DO, FAOAO, MPT; Ahmed Siddiqi, DO; Carl T. Talmo, MD; Antonia F. Chen, MD, MBA

Disclosures

J Am Acad Orthop Surg. 2019;27(18):e804-e818. 

In This Article

Abstract and Introduction

Abstract

Fungal periprosthetic joint infection (PJI) is a devastating complication because it can be difficult to diagnose, manage, and eradicate. Fungal PJI treatment requires a systematic approach. Increased awareness is essential when patients with painful arthroplasties present with immunosuppression, significant comorbidities, multiple surgeries, and history of drug use. Every suspected fungal PJI should be promptly diagnosed using readily available serum and synovial fluid markers. Surgical management involves débridement, antibiotics, and implant retention, one-stage exchange arthroplasty, prosthetic articulating spacers, and two-stage exchange arthroplasty. Because mycotic infections develop robust biofilms, the utility of débridement, antibiotics, and implant retention and one-stage revisions seem limited. A thorough irrigation and débridement is essential to decrease infection burden. Adjunctive local and systemic antifungal therapy is critical, although the agent choice and duration should be tailored appropriately. Future high-quality studies are needed to develop standardized guidelines for the management of fungal PJI.

Introduction

More than 1 million total joint arthroplasties (TJAs) are performed in the United States annually,[1] with notable increases projected over the next few decades.[2] With the increasing number of TJAs, periprosthetic joint infections (PJIs) are projected to increase over time. Although notable improvements have reduced the rate of PJI,[3] infection still remains a common cause of revision TJA.[4]

Although gram-positive organisms are responsible for most PJIs,[5] fungal infections are increasing in prevalence.[6] Fungal PJI represents 1% of all joint infections, and its diagnosis may be more difficult compared with bacterial pathogens because of diverse clinical presentations. Surgical and medical management of fungal PJI are more challenging than gram-positive or negative infections because patients are often immunocompromised with a higher risk of persistent infection. Although increased attention has been dedicated to the diagnosis and management of bacterial septic joints, no standardized guidelines exist for the diagnosis and management of fungal PJI because of its rarity. It is unknown if the protocol for treating bacterial PJI can also be extrapolated to fungi, as there is inconsistent data with regards to the use of systemic, local and oral antifungal agents. This review carefully outlines the diagnosis and management options for fungal PJI.

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