One-Stage Exchange in Candida spp. Periprosthetic Joint Infection: an appropriate solution?

Candida spp. periprosthetic infection (PJI) is a dreaded and difficult-to-treat complication of arthroplasty in which two-stage exchange associated with antifungal therapy is usually advised. One-stage exchange is a valuable option in bacterial PJI with similar outcome and has several advantages. There is a lack of data in an unselected population treated with one stage-exchange for Candida spp. PJI, therefore we investigated retrospectively a series of Candida spp. PJI managed in one-stage scenario.

The outcome of unselected patients treated with one-stage exchange Candida spp. periprosthetic infection do not differ from two-stage exchange reported in the literature.

This retrospective single-center observational study of consecutive and unselected patients with chronic Candida spp. PJI evaluated the outcome of patients treated with implant exchange from January 2012 to December 2021. Patients were included if infection fulfilled EBJIS criteria and had a minimum follow-up of 2 years. Patients were excluded if they had the following surgical strategies: implant retention, implant removal or amputation. Sixteen patients were included: 8 hip and 8 knee infections. Median age and Charlson index were 66 (range, 47-91) and 4 (range, 1-7) respectively. All patients were treated with one-stage exchange and had a mean duration of 106 days (range, 42-184) of appropriate antifungal therapy. At last follow-up, outcome was assessed using: 1) Candida spp. eradication rate and 2) Fillingham classification at 2 years with clinical success defined as tier 1 (Infection control with no continued antibiotic therapy).

Median follow-up was 38 months (range, 25-119). Six patients had infection failure (37.5%) and required a new surgical procedure in the first 2 years of follow-up, all for infection: one had relapsing bacterial infection, 2 had bacterial superinfection and 3 had relapsing Candida spp.

Thus Candida spp. was eradicated in 13 patients (81%) after one-stage exchange. At the final follow-up, 14 patients were able to walk, and one had an above-knee amputation. The functional outcome was unknown for one patient. No death related to the PJI occurred. According to Fillingham's classification, 10 patients (62.5%) had their infection cured after stoppage of antimicrobial therapy and were categorized as tier 1.

In the present series, which included unselected patients, one-stage exchange with an appropriate course of antifungal therapy seems to be a valuable option to eradicate Candida spp. PJI and has a comparable clinical outcome to two-stage exchange series. One-stage exchange is poorly studied for Candida spp. PJI and is often addressed to selected patients. Thus, comparison of both techniques is difficult because of a selection bias. The feasibility of large, prospective and randomized studies on this topic is unlikely, therefore it is crucial to collect data in this population.

IV; uncontrolled retrospective observational study.