What is the recommended treatment for a patient with a rare yeast infection found during joint aspiration before prosthetic surgery?

Management of Rare Yeast Infection Found During Joint Aspiration Before Prosthetic Surgery

A two-stage exchange arthroplasty with systemic antifungal therapy is the recommended treatment for a patient with a rare yeast infection found during joint aspiration before prosthetic surgery. 1, 2

Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis:

• Obtain additional synovial fluid samples for culture and susceptibility testing to identify the specific yeast species
• Measure inflammatory markers (ESR and CRP) which provide the best sensitivity and specificity for diagnosing prosthetic joint infections 3
• Consider blood cultures if fever is present or there is risk of fungemia 4
• Withhold any antibiotics for at least 2 weeks prior to collecting additional cultures to maximize yield 4

Treatment Algorithm

Surgical Management

1. First Stage:

   • Complete removal of all prosthetic components and cement (if present)
   • Thorough debridement of infected tissue
   • Placement of an antifungal-impregnated cement spacer (typically containing amphotericin B)
   • Collection of 5-6 periprosthetic tissue samples for culture 4

2. Interval Period:

   • Systemic antifungal therapy for 6 weeks minimum 1
   • Monitor inflammatory markers (ESR, CRP) for normalization
   • Ensure clinical resolution of infection

3. Second Stage:

   • Reimplantation of new prosthesis after complete resolution of infection
   • Intraoperative tissue cultures at reimplantation to confirm eradication

Antifungal Therapy

• Initial therapy: Fluconazole 400 mg IV daily (if susceptible) 1
• Duration:
  • IV therapy for 6 weeks minimum during prosthesis-free interval
  • Followed by oral fluconazole for at least 6 months after reimplantation 2
  • Some cases may require prolonged or even lifelong suppressive therapy 1

Special Considerations

• Fungal prosthetic joint infections are rare but have high morbidity and treatment failure rates
• Candida species are the most common fungal pathogens in prosthetic joint infections, with C. albicans and C. parapsilosis being most frequent 2
• Risk factors for fungal PJI include:
  • Immunosuppressive therapy
  • Systemic diseases (rheumatoid arthritis, lupus)
  • Diabetes mellitus
  • Malignancy
  • Prior prolonged antibiotic use 2

Pitfalls to Avoid

• Inadequate debridement: Ensure complete removal of all foreign material and infected tissue
• Insufficient antifungal duration: Fungal PJIs require longer treatment courses than bacterial infections
• Premature reimplantation: Ensure complete resolution of infection before second-stage procedure
• Failure to test susceptibility: Antifungal resistance can occur, particularly in non-albicans Candida species
• Missing concomitant bacterial infection: Up to 20% of fungal PJIs have bacterial co-infection 5

By following this approach, the risk of persistent or recurrent infection can be minimized, improving the patient's morbidity, mortality, and quality of life outcomes.