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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Management of Fungal or Atypical Periprosthetic Joint Infections

Liaisons:
Matthias Gebauer MD

Leaders:
Lars Frommelt (International)

Delegates:
Pramod Achan MBBS, Tim N Board MD, Janet Conway MD, William Griffin MD, Nima Heidari MBBS, Glenn Kerr MD, Alex McLaren MD, Sandra Bliss Nelson MD, Marc Nijhof MD, Akos Zahar MD

Vol 1, Num S1, September 2014

 

   

Question 1: What is the definition of fungal or atypical periprosthetic joint infection (PJI)?

Consensus: A fungal or atypical PJI is an infection of a joint arthroplasty caused by fungi or atypical bacteria.

Delegate Vote: Agree: 89%, Disagree: 7%, Abstain: 4% (Strong Consensus)


Question 2: When should fungal organisms be considered as a cause of PJI?

Consensus: A PJI caused by fungi can be considered if fungal pathogens are isolated from periprosthetic tissue cultures or joint aspirations in a patient who has other signs or symptoms of PJI, such as abnormal serology and joint aspiration parameters (neutrophil count and differential). If clinical symptoms raise suspicion for a fungal PJI, repeated joint aspiration may be needed to isolate the infecting organism.

Delegate Vote: Agree: 94%, Disagree: 4%, Abstain: 2% (Strong Consensus)


Question 3: Which host factors (concomitant disease and other factors) predispose to fungal PJI?

Consensus: Predisposing host factors to fungal PJI are: immunosuppression (decreased cellular immunity, neutropenia, corticosteroids or other immunosuppressive drugs, history of organ transplantation, and acquired immunodeficiency syndrome), malignancy and/or the use of antineoplastic agents, drug abuse, prolonged use of antibiotics, presence of indwelling catheters (intravenous, urinary, or parenteral hyperalimentation), diabetes mellitus, malnutrition, rheumatoid arthritis, history of multiple abdominal surgeries, severe burns, tuberculosis, and preceding bacterial infection of the prosthesis.

Delegate Vote: Agree: 95%, Disagree: 2%, Abstain: 3% (Strong Consensus)


Question 4: When fungal organisms are considered, what specimens should be collected, which additional diagnostic tools should be used, and how should they be processed to optimize diagnosis?

Consensus: Fungal selective media must be included and it should be observed that prolonged culture may be required. In specific cases one should expand diagnostic testing to include tissue samples for histological examination, especially in cases where there is a high index of clinical suspicion. Resistance of Candida species to fluconazole has been reported in the literature and susceptibility testing may be requested when resistance to fluconazole is suspected based on isolated species. Antifungal susceptibility testing remains less well developed and utilized than antibacterial testing.

Delegate Vote: Agree: 96%, Disagree: 2%, Abstain: 2% (Strong Consensus)


Question 5: What is the best way to surgically manage fungal PJI: irrigation and debridement, one-stage exchange, two-stage exchange, or permanent resection arthroplasty?

Consensus: On the basis of the current literature, two-stage exchange arthroplasty is the recommended treatment option to manage fungal PJI. However, the success rate is lower than that of bacterial cases.

Delegate Vote: Agree: 95%, Disagree: 2%, Abstain: 3% (Strong Consensus)


Question 6: What are the optimal systemic antifungals administered (type and dose) in the treatment of fungal PJI?

Consensus: Well-established agents for a systemic treatment are the azoles and amphotericin products given either orally or intravenously for a minimum of 6 weeks. Resistance of certain Candida species to fluconazole has been reported in the literature and susceptibility testing should be performed, in collaboration with the microbiologist.

Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2% (Strong Consensus)


Question 7: When treating fungal PJIs in a staged manner, which antifungal or antibacterial medications should be used for the cement spacer? What is the recommended dose?

Consensus: Recent literature confirms that antifungal agents are released in high amounts for local delivery, but there are no clinical studies yet to document the clinical effectiveness. The use of liposomal amphotericin B, loaded in bone cement, has more than an order of magnitude greater release than conventional amphotericin B deoxycholate. There is also controlled release data for azole antifungals, with specific data on the elution of voriconazole from bone cement. There should be a consideration for adding an antibacterial to the bone cement for local delivery in addition to the antifungal.

Delegate Vote: Agree: 94%, Disagree: 2%, Abstain: 4% (Strong Consensus)


Question 8: Which investigations are recommended to monitor fungal PJI and determine timing of reimplantation?

Consensus: C-reactive protein and erythrocyte sedimentation rate are recommended to monitor fungal PJI. There is no clear evidence for the timing of reimplantation based on laboratory tests.

Delegate Vote: Agree: 89%, Disagree: 8%, Abstain: 3% (Strong Consensus)


Question 9: What is the duration for systemic antimicrobial (antifungal) agent administration in the treatment of fungal PJI?

Consensus: Systemic antimicrobial (antifungal) agent administration in the treatment of fungal PJI should be started at the time of removal of the implants (stage one) and continued for at least 6 weeks. It should then be stopped before reimplantation (stage two), the timing of which is based on clinical judgment and laboratory tests. There are no good data to support antifungal agent administration after reimplantation.

Delegate Vote: Agree: 85%, Disagree: 10%, Abstain: 5% (Strong Consensus)