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Key Question

The study aimed to investigate the epidemiology, management, and outcomes of prosthetic joint infections (PJI) caused by Candida species, analyzing factors associated with treatment success and failure.

Key Findings

1. Patient Demographics: The median patient age was 73 years, with hip and knee as primary infection sites.
2. Infection Characteristics: Candida albicans was the most common pathogen (55.8%), followed by Candida parapsilosis (29.4%).
3. Treatment Success Rates: Cure was achieved in 58% of cases, while failure was associated with age >70 years, debridement, antibiotics, and implant retention (DAIR) procedures.
4. Surgical and Medical Management: DAIR had lower cure rates compared to 1- or 2-stage exchange procedures. Antifungal therapies were commonly azoles and echinocandins, with a median duration of 92 days.
5. Coinfection: Bacterial coinfection occurred in 51.3% of cases but did not significantly impact outcomes.

Clinical Implications

• Surgical Management: DAIR is linked to higher failure rates, suggesting that prosthesis removal is preferable, especially for chronic infections.
• Pathogen-Specific Outcomes: Infections with Candida parapsilosis had a more favorable prognosis than those with Candida albicans.
• Age and Infection Risk: Elderly patients face higher risks of treatment failure, indicating a need for more aggressive interventions or careful monitoring.

Strengths

1. Large, Multinational Cohort: The study includes a substantial cohort from multiple international centers, enhancing the generalizability of findings.
2. Detailed Data Collection: Comprehensive data on patient demographics, clinical presentation, treatment regimens, and outcomes are provided.
3. Focus on Rare Infections: This is one of the largest studies specifically addressing Candida PJI, filling a gap in the literature.

Limitations

1. Retrospective Design: Limits the ability to establish causality and may introduce bias due to reliance on existing records.
2. Heterogeneity of Treatment Approaches: Variability in treatment approaches over the study period and across centers may impact outcomes.
3. Limited Power for Subgroup Analyses: The sample may be underpowered to detect some subgroup differences.

Level of Evidence (GRADE Assessment): Low

Rationale: The retrospective nature, along with heterogeneity in treatment protocols and potential selection bias, reduces the certainty of evidence. Although the study is extensive, limitations in study design and outcome standardization warrant a low confidence level in attributing causative treatment effects. Further prospective research, ideally with randomized controlled trials, is necessary to strengthen the evidence for managing Candida PJI.