Candida-induced prosthetic joint infection. A literature review including 72 cases and a case report

Background: The clinical and microbiological characteristics of prosthetic joint infection (PJI) caused by Candida species is described, including 72 cases in the literature and a case of Candida glabrata infection handled at the present centre. Methods: We describe one patient and using the key words fungal prosthetic joint infection' and candida prosthetic joint infection' we searched MEDLINE (National Library of Medicine, Bethesda, MD), Web of Science, CINAHL and Cochrane systematic review databases for case reports of this condition. Results: Out of the 73 patients, 38 were female; mean age at diagnosis was 65.7 ( SD 18) yrs; 50 had risk factors for candidal infection such as systemic disease (e.g. rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus) and/or immunosuppressive therapy in 18 (24.6%) cases, diabetes mellitus in 14 (19.1%), immunosuppression due to malignant or chronic disease in 24 (32.8%) and long-term antibiotic use in four (5.4%) patients. Infection site was the knee in 36 patients and hip in 35; pain was present in 43 patients and swelling in 23 and the mean surgery-diagnosis interval was 32 months. The most frequent species was C. albicans, followed by C. parapsilosis. The diagnosis was obtained from joint fluid aspirate in 33 cases and intra-operative samples in 16. Susceptibility to antifungals was tested in only 21 isolates. The most frequently used antifungals were fluconazole and amphotericin B. Two-stage exchange arthroplasty was performed in 30 patients and resection arthroplasty in 31; 56 patients were cured with a combination of medical and surgical treatment; one patient died from the infection. Conclusion: PJI caused by Candida requires a high index of suspicion; surgery with long-term antifungal therapy is recommended.