CANDIDA PROSTHETIC JOINT INFECTION: A COLLABORATIVE 18-YEAR REVIEW OF TREATMENT AND OUTCOMES FOR HIP AND KNEE ARTHROPLASTY AT A TERTIARY REFERRAL CENTRE

Candida prosthetic joint infection (PJI) is a rare, yet severe, complication that is not widely reported in the literature. Unlike bacterial PJI, there is no clear consensus on the optimal management. Multiple strategies have been described including debridement, antibiotics and implant retention (DAIR), single or two stage revision, excision arthroplasty and amputation. There is similarly no clear consensus on the optimal antifungal strategy. A retrospective cohort study of all confirmed Candida PJIs between 2006 - 2024 at Sheffield Teaching Hospitals. Clinical information was retrieved from electronic patient records. Outcomes were classified as successful or unsuccessful based on the Musculoskeletal Infection Society (MSIS) definition. 21 patients were included – 14 hip arthroplasties and 7 knee arthroplasties. Patients had on average 5.2 operations prior to Candida diagnosis and a sinus was present in 12/21 cases. 15/21 infections were confirmed as polymicrobial. Initial surgical management was a 2-stage revision in 18/21 cases, excision arthroplasty in 1/21, DAIR in 1/21, and washout/debridement in 1/21. Local antifungal monotherapy was used in 15/21 cases with cement as the sole carrier. Exclusively since 2019, local antifungal polytherapy was used in 4/21 cases with Stimulan as an additional carrier to cement. The mean follow-up was 3 years and 9 months. Overall, 10/21 patients had complications due to infection: 8/10 had further surgery, 2/10 were started on suppressive antifungals. 8/21 progressed to a 2nd stage revision, of which 4/8 had complications requiring further surgery. 43% of all cases (9/21) were classified as having a successful outcome. However, local antifungal polytherapy with Stimulan as an additional carrier was associated with a successful outcome in 100% of cases (4/4). This study highlights the significant challenge and complexity of these patients, a possible association between Candida infection and a pre-existing sinus, and a positive trend in outcomes which may be related to the introduction of local antifungal polytherapy and Stimulan as an additional carrier.