A Candida Glabrata-Associated Prosthetic Joint Infection: Case Report and Literature Review

Article Type
Article
Changed
Fri, 03/14/2025 - 09:05
Display Headline

A Candida Glabrata-Associated Prosthetic Joint Infection: Case Report and Literature Review

Author(s)
Lauren Hekman, BS
Nabil Yazdi, MS
Michelle Seu, MD
Chantal Quirk, MD
Bruce Guay, MD
Rabeeya Sabzwari, MD
Amit Dayal, MD

Prosthetic joint infection (PJI) occurs in about 1% to 2% of joint replacements. 1 Risk factors include immunosuppression, diabetes, chronic illnesses, and prolonged operative time.2 Bacterial infections constitute most of these infections, while fungal pathogens account for about 1%. Candida (C.) species, predominantly C. albicans, are responsible for most PJIs.1,3 In contrast, C. glabrata is a rare cause of fungal PJI, with only 18 PJI cases currently reported in the literature.4C. glabrata PJI occurs more frequently among immunosuppressed patients and is associated with a higher treatment failure rate despite antifungal therapy.5 Treatment of fungal PJI is often complicated, involving multiple surgical debridements, prolonged antifungal therapy, and in some cases, prosthesis removal.6 However, given the rarity of C. glabrata as a PJI pathogen, no standardized treatment guidelines exist, leading to potential delays in diagnosis and tailored treatment.7,8

CASE PRESENTATION

A male Vietnam veteran aged 75 years presented to the emergency department in July 2023 with a fluid collection over his left hip surgical incision site. The patient had a complex medical history that included chronic kidney disease, well-controlled type 2 diabetes, hypertension, and osteoarthritis. His history was further complicated by nonalcoholic steatohepatitis with hepatocellular carcinoma that was treated with transarterial radioembolization and yttrium-90. The patient had undergone a left total hip arthroplasty in 1996 and subsequent open reduction and internal fixation about 9 months prior to his presentation. The patient reported the fluid had been present for about 6 weeks, while he received outpatient monitoring by the orthopedic surgery service. He sought emergency care after noting a moderate amount of purulent discharge on his clothing originating from his hip. In the week prior to admission, the patient observed progressive erythema, warmth, and tenderness over the incision site. Despite these symptoms, the patient remained ambulatory and able to walk long distances with the use of an assistive device.

Upon presentation, the patient was afebrile and normotensive. Laboratory testing revealed an elevated erythrocyte sedimentation rate of 77 mm/h (reference range, 0-20 mm/h) and a C-reactive protein of 9.8 mg/L (reference range, 0-2.5 mg/L), suggesting an underlying infectious process. A physical examination revealed a well-healed incision over the left hip with a poorly defined area of fluctuance and evidence of wound dehiscence. The left lower extremity was swollen with 2+ pitting edema, but tenderness was localized to the incision site. Magnetic resonance imaging of the left hip revealed a multiloculated fluid collection abutting the left greater trochanter with extension to the skin surface and inferior extension along the entire length of the surgical fixation hardware (Figure).

FDP04203134_F1AFDP04203134_F1B

Upon admission, orthopedic surgery performed a bedside aspiration of the fluid collection. Samples were sent for analysis, including cell count and bacterial and fungal cultures. Initial blood cultures were sterile. Due to concerns for a bacterial infection, the patient was started on empiric intravenous (IV) ceftriaxone 2 g/day and IV vancomycin 1250 mg/day. Synovial fluid analysis revealed an elevated white blood cell count of 45,000/ìL, but bacterial cultures were negative. Five days after admission, the fungal culture from the left hip wound was notable for presence of C. glabrata, prompting an infectious diseases (ID) consultation. IV micafungin 100 mg/day was initiated as empiric antifungal therapy.

ID and orthopedic surgery teams determined that a combined medical and surgical approach would be best suited for infection control. They proposed 2 main approaches: complete hardware replacement with washout, which carried a higher morbidity risk but a better chance of infection resolution, or partial hardware replacement with washout, which was associated with a lower morbidity risk but a higher risk of infection persistence and recurrence. This decision was particularly challenging for the patient, who prioritized maintaining his functional status, including his ability to continue dancing for pleasure. The patient opted for a more conservative approach, electing to proceed with antifungal therapy and debridement while retaining the prosthetic joint.

After 11 days of hospitalization, the patient was discharged with a peripherally inserted central catheter for long-term antifungal infusions of micafungin 150 mg/day at home. Fungal sensitivity test results several days after discharge confirmed susceptibility to micafungin.

About 2 weeks after discharge, the patient underwent debridement and implant retention (DAIR). Wound cultures were positive for C. glabrata, Enterococcus faecalis, Staphylococcus epidermidis, and Corynebacterium tuberculostearicum. Based on susceptibilities, he completed a 2-month course of IV micafungin 150 mg daily and daptomycin 750 mg daily, followed by an oral suppressive regimen consisting of doxycycline 100 mg twice daily, amoxicillin-clavulanate 2 g twice daily, and fluconazole initially 800 mg daily adjusted to 400 mg daily. The patient continued wound management with twice-daily dressing changes.

Nine months after DAIR, the patient remained on suppressive antifungal and antibacterial therapy. He continued to experience serous drainage from the wound, which greatly affected his quality of life. After discussion with his family and the orthopedic surgery team, he agreed to proceed with a 2-staged revision arthroplasty involving prosthetic explant and antibiotic spacer placement. However, the surgery was postponed due to findings of anemia (hemoglobin, 8.9 g/dL) and thrombocytopenia (platelet count, 73 x 103/λL). At the time of this report, the patient was being monitored closely with his multidisciplinary care team for the planned orthopedic procedure.

DISCUSSION

PJI is the most common cause of primary hip arthroplasty failure; however, fungal species only make up about 1% of PJIs.3,9-11 Patients are typically immunocompromised, undergoing antineoplastic therapies for malignancy, or have other comorbid conditions such as diabetes.12,13C. glabrata presents a unique diagnostic and therapeutic challenge as it is not only rare but also notorious for its resistance to common antifungal agents. C. glabrata is known to develop multidrug resistance through the rapid accumulation of genomic mutations.14 Its propensity towards forming protective biofilm also arms it with intrinsic resistance to agents like fluconazole.15 Furthermore, based on a review of the available reports in the literature, C. glabrata PJIs are often insidious and present with symptoms closely mimicking those of bacterial PJIs, as it did in the patient in this case.16

Synovial fluid analysis, fungal cultures, and sensitivity testing are paramount for ensuring proper diagnosis for fungal PJI. The patient in this case was empirically treated with micafungin based on recommendations from the ID team. When the sensitivities results were reviewed, the same antifungal therapy was continued. Echinocandins have a favorable toxicity profile in long-term use, as well as efficacy against biofilm-producing organisms like C. glabrata.17,18

While there are a few cases citing DAIR as a feasible surgical strategy for treating fungal PJI, more recent studies have reported greater success with a 2-staged revision arthroplasty involving some combination of debridement, placement of antibiotic-loaded bone cement spacers, and partial or total exchange of the infected prosthetic joint.4,19-23 In this case, complete hardware replacement would have offered the patient the most favorable outlook for eliminating this fungal infection. However, given the patient’s advanced age, significant underlying comorbidities, and functional status, medical management with antifungal therapy and DAIR was favored.

Based on the discussion from the 6-month follow-up visit, the patient was experiencing progressive and persistent wound drainage and frequent dressing changes, highlighting the limitations of medical management for PJI in the setting of retained prosthesis. If the patient ultimately proceeds with a more invasive surgical intervention, another important consideration will be the likelihood of fungal PJI recurrence. At present, fungal PJI recurrence rates following antifungal and surgical treatment have been reported to range between 0% to 50%, which is too imprecise to be considered clinically useful.22-24

Given the ambiguity surrounding management guidelines and limited treatment options, it is crucial to emphasize the timeline of this patient’s clinical presentation and subsequent course of treatment. Upon presentation to the ED in late July, fungal PJI was considered less likely. Initial blood cultures from presentation were negative, which is common with PJIs. It was not until 5 days later that the left hip wound culture showed moderate growth of C. glabrata. Identifying a PJI is clinically challenging due to the lack of standardized diagnostic criteria. However, timely identification and diagnosis of fungal PJI with appropriate antifungal therapy, in patients with limited curative options due to comorbidities, can significantly improve quality of life and overall outcomes.25 Routine fungal and mycobacterial cultures are not currently recommended in PJI guidelines, but this case illustrates it is imperative in immunocompromised hosts.26

This case and the current paucity of similar cases in the literature stress the importance of clinicians publishing their experience in the management of fungal PJI. We strongly recommend that clinicians approach each suspected PJI with careful consideration of the patient’s unique risk factors, comorbidities, and goals of care, when deciding on a curative vs suppressive approach to therapy.

CONCLUSIONS

This case report highlights the importance of considering fungal pathogens for PJIs, especially in high-risk patients, the value of obtaining fungal cultures, the necessity of a multidisciplinary approach, the role of antifungal susceptibility testing, and consideration for the feasibility of a surgical intervention. It underscores the challenges in diagnosis and treatment of C. glabrata-associated PJI, emphasizing the importance of clinician experience-sharing in developing evidence-based management strategies. As the understanding of fungal PJI evolves, continued research and clinical data collection remain crucial for improving patient outcomes in the management of these complex cases.

References
  1. Osmon DR, Berbari EF, Berendt AR, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):1-10. doi:10.1093/cid/cis966
  2. Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015;3(16):233. doi:10.3978/j.issn.2305-5839.2015.09.26
  3. Darouiche RO, Hamill RJ, Musher DM, Young EJ, Harris RL. Periprosthetic candidal infections following arthroplasty. Rev Infect Dis. 1989;11(1):89-96. doi:10.1093/clinids/11.1.89
  4. Koutserimpas C, Zervakis SG, Maraki S, et al. Non-albicans Candida prosthetic joint infections: a systematic review of treatment. World J Clin Cases. 2019;7(12):1430- 1443. doi:10.12998/wjcc.v7.i12.1430
  5. Fidel PL Jr, Vazquez JA, Sobel JD. Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Microbiol Rev. 1999;12(1):80-96. doi:10.1128/CMR.12.1.80
  6. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  7. Lee YR, Kim HJ, Lee EJ, Sohn JW, Kim MJ, Yoon YK. Prosthetic joint infections caused by candida species: a systematic review and a case series. Mycopathologia. 2019;184(1):23-33. doi:10.1007/s11046-018-0286-1
  8. Herndon CL, Rowe TM, Metcalf RW, et al. Treatment outcomes of fungal periprosthetic joint infection. J Arthroplasty. 2023;38(11):2436-2440.e1. doi:10.1016/j.arth.2023.05.009
  9. Delaunay C, Hamadouche M, Girard J, Duhamel A; SoFCOT. What are the causes for failures of primary hip arthroplasties in France? Clin Orthop Relat Res. 2013;471(12): 3863-3869. doi:10.1007/s11999-013-2935-5
  10. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1): 128-133. doi:10.2106/JBJS.H.00155
  11. Furnes O, Lie SA, Espehaug B, Vollset SE, Engesaeter LB, Havelin LI. Hip disease and the prognosis of total hip replacements. A review of 53,698 primary total hip replacements reported to the Norwegian Arthroplasty Register 1987-99. J Bone Joint Surg Br. 2001;83(4):579-586. doi:10.1302/0301-620x.83b4.11223
  12. Gonzalez MR, Bedi ADS, Karczewski D, Lozano-Calderon SA. Treatment and outcomes of fungal prosthetic joint infections: a systematic review of 225 cases. J Arthroplasty. 2023;38(11):2464-2471.e1. doi:10.1016/j.arth.2023.05.003
  13. Gonzalez MR, Pretell-Mazzini J, Lozano-Calderon SA. Risk factors and management of prosthetic joint infections in megaprostheses-a review of the literature. Antibiotics (Basel). 2023;13(1):25. doi:10.3390/antibiotics13010025
  14. Biswas C, Chen SC, Halliday C, et al. Identification of genetic markers of resistance to echinocandins, azoles and 5-fluorocytosine in Candida glabrata by next-generation sequencing: a feasibility study. Clin Microbiol Infect. 2017;23(9):676.e7-676.e10. doi:10.1016/j.cmi.2017.03.014
  15. Hassan Y, Chew SY, Than LTL. Candida glabrata: pathogenicity and resistance mechanisms for adaptation and survival. J Fungi (Basel). 2021;7(8):667. doi:10.3390/jof7080667
  16. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  17. Pierce CG, Uppuluri P, Tristan AR, et al. A simple and reproducible 96-well plate-based method for the formation of fungal biofilms and its application to antifungal susceptibility testing. Nat Protoc. 2008;3(9):1494-1500. doi:10.1038/nport.2008.141
  18. Koutserimpas C, Samonis G, Velivassakis E, Iliopoulou- Kosmadaki S, Kontakis G, Kofteridis DP. Candida glabrata prosthetic joint infection, successfully treated with anidulafungin: a case report and review of the literature. Mycoses. 2018;61(4):266-269. doi:10.1111/myc.12736
  19. Brooks DH, Pupparo F. Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. J Arthroplasty. 1998;13(6):707-712. doi:10.1016/s0883-5403(98)80017-x
  20. Merrer J, Dupont B, Nieszkowska A, De Jonghe B, Outin H. Candida albicans prosthetic arthritis treated with fluconazole alone. J Infect. 2001;42(3):208-209. doi:10.1053/jinf.2001.0819
  21. Koutserimpas C, Naoum S, Alpantaki K, et al. Fungal prosthetic joint infection in revised knee arthroplasty: an orthopaedic surgeon’s nightmare. Diagnostics (Basel). 2022;12(7):1606. doi:10.3390/diagnostics12071606
  22. Gao Z, Li X, Du Y, Peng Y, Wu W, Zhou Y. Success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and potential risk factors of treatment failure: a retrospective study. Med Sci Monit. 2018;24:5549-5557. doi:10.12659/MSM.909168
  23. Hwang BH, Yoon JY, Nam CH, et al. Fungal periprosthetic joint infection after primary total knee replacement. J Bone Joint Surg Br. 2012;94(5):656-659. doi:10.1302/0301-620X.94B5.28125
  24. Ueng SW, Lee CY, Hu CC, Hsieh PH, Chang Y. What is the success of treatment of hip and knee candidal periprosthetic joint infection? Clin Orthop Relat Res. 2013;471(9):3002-3009. doi:10.1007/s11999-013-3007-6
  25. Nodzo, Scott R. MD; Bauer, Thomas MD, PhD; Pottinger, et al. Conventional diagnostic challenges in periprosthetic joint infection. J Am Acad Orthop Surg. 2015;23 Suppl:S18-S25. doi:10.5435/JAAOS-D-14-00385
  26. American Academy of Orthopaedic Surgeons. Diagnosis and prevention of periprosthetic joint infections. March 11, 2019. Accessed February 5, 2025. https://www.aaos.org/pjicpg
Article PDF
FDP04203134.pdf
Author and Disclosure Information

Lauren Hekman, BSa; Nabil Yazdi, MSa; Michelle Seu, MDb; Chantal Quirk, MDb; Bruce Guay, MDa,b,c; Rabeeya Sabzwari, MDb,c; Amit Dayal, MDa,b,c

Author affiliations
aLoyola University Chicago, Illinois
bLoyola University Medical Center, Maywood, Illinois
cEdward Hines Jr. Veterans Affairs Hospital, Hines, Illinois

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Amit Dayal (amit.dayal@va.gov)

Fed Pract. 2025;42(3). Published online March 17. doi:10.12788/fp.0563

Issue
Federal Practitioner - 42(3)
Publications
Federal Practitioner
Topics
Orthopedics
Hip
Mixed Topics
Page Number
134-137
Sections
Case Reports
Author(s)
Lauren Hekman, BS
Nabil Yazdi, MS
Michelle Seu, MD
Chantal Quirk, MD
Bruce Guay, MD
Rabeeya Sabzwari, MD
Amit Dayal, MD
Author(s)
Lauren Hekman, BS
Nabil Yazdi, MS
Michelle Seu, MD
Chantal Quirk, MD
Bruce Guay, MD
Rabeeya Sabzwari, MD
Amit Dayal, MD
Author and Disclosure Information

Lauren Hekman, BSa; Nabil Yazdi, MSa; Michelle Seu, MDb; Chantal Quirk, MDb; Bruce Guay, MDa,b,c; Rabeeya Sabzwari, MDb,c; Amit Dayal, MDa,b,c

Author affiliations
aLoyola University Chicago, Illinois
bLoyola University Medical Center, Maywood, Illinois
cEdward Hines Jr. Veterans Affairs Hospital, Hines, Illinois

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Amit Dayal (amit.dayal@va.gov)

Fed Pract. 2025;42(3). Published online March 17. doi:10.12788/fp.0563

Author and Disclosure Information

Lauren Hekman, BSa; Nabil Yazdi, MSa; Michelle Seu, MDb; Chantal Quirk, MDb; Bruce Guay, MDa,b,c; Rabeeya Sabzwari, MDb,c; Amit Dayal, MDa,b,c

Author affiliations
aLoyola University Chicago, Illinois
bLoyola University Medical Center, Maywood, Illinois
cEdward Hines Jr. Veterans Affairs Hospital, Hines, Illinois

Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.

Correspondence: Amit Dayal (amit.dayal@va.gov)

Fed Pract. 2025;42(3). Published online March 17. doi:10.12788/fp.0563

Article PDF
FDP04203134.pdf
Article PDF
FDP04203134.pdf

Prosthetic joint infection (PJI) occurs in about 1% to 2% of joint replacements. 1 Risk factors include immunosuppression, diabetes, chronic illnesses, and prolonged operative time.2 Bacterial infections constitute most of these infections, while fungal pathogens account for about 1%. Candida (C.) species, predominantly C. albicans, are responsible for most PJIs.1,3 In contrast, C. glabrata is a rare cause of fungal PJI, with only 18 PJI cases currently reported in the literature.4C. glabrata PJI occurs more frequently among immunosuppressed patients and is associated with a higher treatment failure rate despite antifungal therapy.5 Treatment of fungal PJI is often complicated, involving multiple surgical debridements, prolonged antifungal therapy, and in some cases, prosthesis removal.6 However, given the rarity of C. glabrata as a PJI pathogen, no standardized treatment guidelines exist, leading to potential delays in diagnosis and tailored treatment.7,8

CASE PRESENTATION

A male Vietnam veteran aged 75 years presented to the emergency department in July 2023 with a fluid collection over his left hip surgical incision site. The patient had a complex medical history that included chronic kidney disease, well-controlled type 2 diabetes, hypertension, and osteoarthritis. His history was further complicated by nonalcoholic steatohepatitis with hepatocellular carcinoma that was treated with transarterial radioembolization and yttrium-90. The patient had undergone a left total hip arthroplasty in 1996 and subsequent open reduction and internal fixation about 9 months prior to his presentation. The patient reported the fluid had been present for about 6 weeks, while he received outpatient monitoring by the orthopedic surgery service. He sought emergency care after noting a moderate amount of purulent discharge on his clothing originating from his hip. In the week prior to admission, the patient observed progressive erythema, warmth, and tenderness over the incision site. Despite these symptoms, the patient remained ambulatory and able to walk long distances with the use of an assistive device.

Upon presentation, the patient was afebrile and normotensive. Laboratory testing revealed an elevated erythrocyte sedimentation rate of 77 mm/h (reference range, 0-20 mm/h) and a C-reactive protein of 9.8 mg/L (reference range, 0-2.5 mg/L), suggesting an underlying infectious process. A physical examination revealed a well-healed incision over the left hip with a poorly defined area of fluctuance and evidence of wound dehiscence. The left lower extremity was swollen with 2+ pitting edema, but tenderness was localized to the incision site. Magnetic resonance imaging of the left hip revealed a multiloculated fluid collection abutting the left greater trochanter with extension to the skin surface and inferior extension along the entire length of the surgical fixation hardware (Figure).

FDP04203134_F1AFDP04203134_F1B

Upon admission, orthopedic surgery performed a bedside aspiration of the fluid collection. Samples were sent for analysis, including cell count and bacterial and fungal cultures. Initial blood cultures were sterile. Due to concerns for a bacterial infection, the patient was started on empiric intravenous (IV) ceftriaxone 2 g/day and IV vancomycin 1250 mg/day. Synovial fluid analysis revealed an elevated white blood cell count of 45,000/ìL, but bacterial cultures were negative. Five days after admission, the fungal culture from the left hip wound was notable for presence of C. glabrata, prompting an infectious diseases (ID) consultation. IV micafungin 100 mg/day was initiated as empiric antifungal therapy.

ID and orthopedic surgery teams determined that a combined medical and surgical approach would be best suited for infection control. They proposed 2 main approaches: complete hardware replacement with washout, which carried a higher morbidity risk but a better chance of infection resolution, or partial hardware replacement with washout, which was associated with a lower morbidity risk but a higher risk of infection persistence and recurrence. This decision was particularly challenging for the patient, who prioritized maintaining his functional status, including his ability to continue dancing for pleasure. The patient opted for a more conservative approach, electing to proceed with antifungal therapy and debridement while retaining the prosthetic joint.

After 11 days of hospitalization, the patient was discharged with a peripherally inserted central catheter for long-term antifungal infusions of micafungin 150 mg/day at home. Fungal sensitivity test results several days after discharge confirmed susceptibility to micafungin.

About 2 weeks after discharge, the patient underwent debridement and implant retention (DAIR). Wound cultures were positive for C. glabrata, Enterococcus faecalis, Staphylococcus epidermidis, and Corynebacterium tuberculostearicum. Based on susceptibilities, he completed a 2-month course of IV micafungin 150 mg daily and daptomycin 750 mg daily, followed by an oral suppressive regimen consisting of doxycycline 100 mg twice daily, amoxicillin-clavulanate 2 g twice daily, and fluconazole initially 800 mg daily adjusted to 400 mg daily. The patient continued wound management with twice-daily dressing changes.

Nine months after DAIR, the patient remained on suppressive antifungal and antibacterial therapy. He continued to experience serous drainage from the wound, which greatly affected his quality of life. After discussion with his family and the orthopedic surgery team, he agreed to proceed with a 2-staged revision arthroplasty involving prosthetic explant and antibiotic spacer placement. However, the surgery was postponed due to findings of anemia (hemoglobin, 8.9 g/dL) and thrombocytopenia (platelet count, 73 x 103/λL). At the time of this report, the patient was being monitored closely with his multidisciplinary care team for the planned orthopedic procedure.

DISCUSSION

PJI is the most common cause of primary hip arthroplasty failure; however, fungal species only make up about 1% of PJIs.3,9-11 Patients are typically immunocompromised, undergoing antineoplastic therapies for malignancy, or have other comorbid conditions such as diabetes.12,13C. glabrata presents a unique diagnostic and therapeutic challenge as it is not only rare but also notorious for its resistance to common antifungal agents. C. glabrata is known to develop multidrug resistance through the rapid accumulation of genomic mutations.14 Its propensity towards forming protective biofilm also arms it with intrinsic resistance to agents like fluconazole.15 Furthermore, based on a review of the available reports in the literature, C. glabrata PJIs are often insidious and present with symptoms closely mimicking those of bacterial PJIs, as it did in the patient in this case.16

Synovial fluid analysis, fungal cultures, and sensitivity testing are paramount for ensuring proper diagnosis for fungal PJI. The patient in this case was empirically treated with micafungin based on recommendations from the ID team. When the sensitivities results were reviewed, the same antifungal therapy was continued. Echinocandins have a favorable toxicity profile in long-term use, as well as efficacy against biofilm-producing organisms like C. glabrata.17,18

While there are a few cases citing DAIR as a feasible surgical strategy for treating fungal PJI, more recent studies have reported greater success with a 2-staged revision arthroplasty involving some combination of debridement, placement of antibiotic-loaded bone cement spacers, and partial or total exchange of the infected prosthetic joint.4,19-23 In this case, complete hardware replacement would have offered the patient the most favorable outlook for eliminating this fungal infection. However, given the patient’s advanced age, significant underlying comorbidities, and functional status, medical management with antifungal therapy and DAIR was favored.

Based on the discussion from the 6-month follow-up visit, the patient was experiencing progressive and persistent wound drainage and frequent dressing changes, highlighting the limitations of medical management for PJI in the setting of retained prosthesis. If the patient ultimately proceeds with a more invasive surgical intervention, another important consideration will be the likelihood of fungal PJI recurrence. At present, fungal PJI recurrence rates following antifungal and surgical treatment have been reported to range between 0% to 50%, which is too imprecise to be considered clinically useful.22-24

Given the ambiguity surrounding management guidelines and limited treatment options, it is crucial to emphasize the timeline of this patient’s clinical presentation and subsequent course of treatment. Upon presentation to the ED in late July, fungal PJI was considered less likely. Initial blood cultures from presentation were negative, which is common with PJIs. It was not until 5 days later that the left hip wound culture showed moderate growth of C. glabrata. Identifying a PJI is clinically challenging due to the lack of standardized diagnostic criteria. However, timely identification and diagnosis of fungal PJI with appropriate antifungal therapy, in patients with limited curative options due to comorbidities, can significantly improve quality of life and overall outcomes.25 Routine fungal and mycobacterial cultures are not currently recommended in PJI guidelines, but this case illustrates it is imperative in immunocompromised hosts.26

This case and the current paucity of similar cases in the literature stress the importance of clinicians publishing their experience in the management of fungal PJI. We strongly recommend that clinicians approach each suspected PJI with careful consideration of the patient’s unique risk factors, comorbidities, and goals of care, when deciding on a curative vs suppressive approach to therapy.

CONCLUSIONS

This case report highlights the importance of considering fungal pathogens for PJIs, especially in high-risk patients, the value of obtaining fungal cultures, the necessity of a multidisciplinary approach, the role of antifungal susceptibility testing, and consideration for the feasibility of a surgical intervention. It underscores the challenges in diagnosis and treatment of C. glabrata-associated PJI, emphasizing the importance of clinician experience-sharing in developing evidence-based management strategies. As the understanding of fungal PJI evolves, continued research and clinical data collection remain crucial for improving patient outcomes in the management of these complex cases.

Prosthetic joint infection (PJI) occurs in about 1% to 2% of joint replacements. 1 Risk factors include immunosuppression, diabetes, chronic illnesses, and prolonged operative time.2 Bacterial infections constitute most of these infections, while fungal pathogens account for about 1%. Candida (C.) species, predominantly C. albicans, are responsible for most PJIs.1,3 In contrast, C. glabrata is a rare cause of fungal PJI, with only 18 PJI cases currently reported in the literature.4C. glabrata PJI occurs more frequently among immunosuppressed patients and is associated with a higher treatment failure rate despite antifungal therapy.5 Treatment of fungal PJI is often complicated, involving multiple surgical debridements, prolonged antifungal therapy, and in some cases, prosthesis removal.6 However, given the rarity of C. glabrata as a PJI pathogen, no standardized treatment guidelines exist, leading to potential delays in diagnosis and tailored treatment.7,8

CASE PRESENTATION

A male Vietnam veteran aged 75 years presented to the emergency department in July 2023 with a fluid collection over his left hip surgical incision site. The patient had a complex medical history that included chronic kidney disease, well-controlled type 2 diabetes, hypertension, and osteoarthritis. His history was further complicated by nonalcoholic steatohepatitis with hepatocellular carcinoma that was treated with transarterial radioembolization and yttrium-90. The patient had undergone a left total hip arthroplasty in 1996 and subsequent open reduction and internal fixation about 9 months prior to his presentation. The patient reported the fluid had been present for about 6 weeks, while he received outpatient monitoring by the orthopedic surgery service. He sought emergency care after noting a moderate amount of purulent discharge on his clothing originating from his hip. In the week prior to admission, the patient observed progressive erythema, warmth, and tenderness over the incision site. Despite these symptoms, the patient remained ambulatory and able to walk long distances with the use of an assistive device.

Upon presentation, the patient was afebrile and normotensive. Laboratory testing revealed an elevated erythrocyte sedimentation rate of 77 mm/h (reference range, 0-20 mm/h) and a C-reactive protein of 9.8 mg/L (reference range, 0-2.5 mg/L), suggesting an underlying infectious process. A physical examination revealed a well-healed incision over the left hip with a poorly defined area of fluctuance and evidence of wound dehiscence. The left lower extremity was swollen with 2+ pitting edema, but tenderness was localized to the incision site. Magnetic resonance imaging of the left hip revealed a multiloculated fluid collection abutting the left greater trochanter with extension to the skin surface and inferior extension along the entire length of the surgical fixation hardware (Figure).

FDP04203134_F1AFDP04203134_F1B

Upon admission, orthopedic surgery performed a bedside aspiration of the fluid collection. Samples were sent for analysis, including cell count and bacterial and fungal cultures. Initial blood cultures were sterile. Due to concerns for a bacterial infection, the patient was started on empiric intravenous (IV) ceftriaxone 2 g/day and IV vancomycin 1250 mg/day. Synovial fluid analysis revealed an elevated white blood cell count of 45,000/ìL, but bacterial cultures were negative. Five days after admission, the fungal culture from the left hip wound was notable for presence of C. glabrata, prompting an infectious diseases (ID) consultation. IV micafungin 100 mg/day was initiated as empiric antifungal therapy.

ID and orthopedic surgery teams determined that a combined medical and surgical approach would be best suited for infection control. They proposed 2 main approaches: complete hardware replacement with washout, which carried a higher morbidity risk but a better chance of infection resolution, or partial hardware replacement with washout, which was associated with a lower morbidity risk but a higher risk of infection persistence and recurrence. This decision was particularly challenging for the patient, who prioritized maintaining his functional status, including his ability to continue dancing for pleasure. The patient opted for a more conservative approach, electing to proceed with antifungal therapy and debridement while retaining the prosthetic joint.

After 11 days of hospitalization, the patient was discharged with a peripherally inserted central catheter for long-term antifungal infusions of micafungin 150 mg/day at home. Fungal sensitivity test results several days after discharge confirmed susceptibility to micafungin.

About 2 weeks after discharge, the patient underwent debridement and implant retention (DAIR). Wound cultures were positive for C. glabrata, Enterococcus faecalis, Staphylococcus epidermidis, and Corynebacterium tuberculostearicum. Based on susceptibilities, he completed a 2-month course of IV micafungin 150 mg daily and daptomycin 750 mg daily, followed by an oral suppressive regimen consisting of doxycycline 100 mg twice daily, amoxicillin-clavulanate 2 g twice daily, and fluconazole initially 800 mg daily adjusted to 400 mg daily. The patient continued wound management with twice-daily dressing changes.

Nine months after DAIR, the patient remained on suppressive antifungal and antibacterial therapy. He continued to experience serous drainage from the wound, which greatly affected his quality of life. After discussion with his family and the orthopedic surgery team, he agreed to proceed with a 2-staged revision arthroplasty involving prosthetic explant and antibiotic spacer placement. However, the surgery was postponed due to findings of anemia (hemoglobin, 8.9 g/dL) and thrombocytopenia (platelet count, 73 x 103/λL). At the time of this report, the patient was being monitored closely with his multidisciplinary care team for the planned orthopedic procedure.

DISCUSSION

PJI is the most common cause of primary hip arthroplasty failure; however, fungal species only make up about 1% of PJIs.3,9-11 Patients are typically immunocompromised, undergoing antineoplastic therapies for malignancy, or have other comorbid conditions such as diabetes.12,13C. glabrata presents a unique diagnostic and therapeutic challenge as it is not only rare but also notorious for its resistance to common antifungal agents. C. glabrata is known to develop multidrug resistance through the rapid accumulation of genomic mutations.14 Its propensity towards forming protective biofilm also arms it with intrinsic resistance to agents like fluconazole.15 Furthermore, based on a review of the available reports in the literature, C. glabrata PJIs are often insidious and present with symptoms closely mimicking those of bacterial PJIs, as it did in the patient in this case.16

Synovial fluid analysis, fungal cultures, and sensitivity testing are paramount for ensuring proper diagnosis for fungal PJI. The patient in this case was empirically treated with micafungin based on recommendations from the ID team. When the sensitivities results were reviewed, the same antifungal therapy was continued. Echinocandins have a favorable toxicity profile in long-term use, as well as efficacy against biofilm-producing organisms like C. glabrata.17,18

While there are a few cases citing DAIR as a feasible surgical strategy for treating fungal PJI, more recent studies have reported greater success with a 2-staged revision arthroplasty involving some combination of debridement, placement of antibiotic-loaded bone cement spacers, and partial or total exchange of the infected prosthetic joint.4,19-23 In this case, complete hardware replacement would have offered the patient the most favorable outlook for eliminating this fungal infection. However, given the patient’s advanced age, significant underlying comorbidities, and functional status, medical management with antifungal therapy and DAIR was favored.

Based on the discussion from the 6-month follow-up visit, the patient was experiencing progressive and persistent wound drainage and frequent dressing changes, highlighting the limitations of medical management for PJI in the setting of retained prosthesis. If the patient ultimately proceeds with a more invasive surgical intervention, another important consideration will be the likelihood of fungal PJI recurrence. At present, fungal PJI recurrence rates following antifungal and surgical treatment have been reported to range between 0% to 50%, which is too imprecise to be considered clinically useful.22-24

Given the ambiguity surrounding management guidelines and limited treatment options, it is crucial to emphasize the timeline of this patient’s clinical presentation and subsequent course of treatment. Upon presentation to the ED in late July, fungal PJI was considered less likely. Initial blood cultures from presentation were negative, which is common with PJIs. It was not until 5 days later that the left hip wound culture showed moderate growth of C. glabrata. Identifying a PJI is clinically challenging due to the lack of standardized diagnostic criteria. However, timely identification and diagnosis of fungal PJI with appropriate antifungal therapy, in patients with limited curative options due to comorbidities, can significantly improve quality of life and overall outcomes.25 Routine fungal and mycobacterial cultures are not currently recommended in PJI guidelines, but this case illustrates it is imperative in immunocompromised hosts.26

This case and the current paucity of similar cases in the literature stress the importance of clinicians publishing their experience in the management of fungal PJI. We strongly recommend that clinicians approach each suspected PJI with careful consideration of the patient’s unique risk factors, comorbidities, and goals of care, when deciding on a curative vs suppressive approach to therapy.

CONCLUSIONS

This case report highlights the importance of considering fungal pathogens for PJIs, especially in high-risk patients, the value of obtaining fungal cultures, the necessity of a multidisciplinary approach, the role of antifungal susceptibility testing, and consideration for the feasibility of a surgical intervention. It underscores the challenges in diagnosis and treatment of C. glabrata-associated PJI, emphasizing the importance of clinician experience-sharing in developing evidence-based management strategies. As the understanding of fungal PJI evolves, continued research and clinical data collection remain crucial for improving patient outcomes in the management of these complex cases.

References
  1. Osmon DR, Berbari EF, Berendt AR, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):1-10. doi:10.1093/cid/cis966
  2. Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015;3(16):233. doi:10.3978/j.issn.2305-5839.2015.09.26
  3. Darouiche RO, Hamill RJ, Musher DM, Young EJ, Harris RL. Periprosthetic candidal infections following arthroplasty. Rev Infect Dis. 1989;11(1):89-96. doi:10.1093/clinids/11.1.89
  4. Koutserimpas C, Zervakis SG, Maraki S, et al. Non-albicans Candida prosthetic joint infections: a systematic review of treatment. World J Clin Cases. 2019;7(12):1430- 1443. doi:10.12998/wjcc.v7.i12.1430
  5. Fidel PL Jr, Vazquez JA, Sobel JD. Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Microbiol Rev. 1999;12(1):80-96. doi:10.1128/CMR.12.1.80
  6. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  7. Lee YR, Kim HJ, Lee EJ, Sohn JW, Kim MJ, Yoon YK. Prosthetic joint infections caused by candida species: a systematic review and a case series. Mycopathologia. 2019;184(1):23-33. doi:10.1007/s11046-018-0286-1
  8. Herndon CL, Rowe TM, Metcalf RW, et al. Treatment outcomes of fungal periprosthetic joint infection. J Arthroplasty. 2023;38(11):2436-2440.e1. doi:10.1016/j.arth.2023.05.009
  9. Delaunay C, Hamadouche M, Girard J, Duhamel A; SoFCOT. What are the causes for failures of primary hip arthroplasties in France? Clin Orthop Relat Res. 2013;471(12): 3863-3869. doi:10.1007/s11999-013-2935-5
  10. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1): 128-133. doi:10.2106/JBJS.H.00155
  11. Furnes O, Lie SA, Espehaug B, Vollset SE, Engesaeter LB, Havelin LI. Hip disease and the prognosis of total hip replacements. A review of 53,698 primary total hip replacements reported to the Norwegian Arthroplasty Register 1987-99. J Bone Joint Surg Br. 2001;83(4):579-586. doi:10.1302/0301-620x.83b4.11223
  12. Gonzalez MR, Bedi ADS, Karczewski D, Lozano-Calderon SA. Treatment and outcomes of fungal prosthetic joint infections: a systematic review of 225 cases. J Arthroplasty. 2023;38(11):2464-2471.e1. doi:10.1016/j.arth.2023.05.003
  13. Gonzalez MR, Pretell-Mazzini J, Lozano-Calderon SA. Risk factors and management of prosthetic joint infections in megaprostheses-a review of the literature. Antibiotics (Basel). 2023;13(1):25. doi:10.3390/antibiotics13010025
  14. Biswas C, Chen SC, Halliday C, et al. Identification of genetic markers of resistance to echinocandins, azoles and 5-fluorocytosine in Candida glabrata by next-generation sequencing: a feasibility study. Clin Microbiol Infect. 2017;23(9):676.e7-676.e10. doi:10.1016/j.cmi.2017.03.014
  15. Hassan Y, Chew SY, Than LTL. Candida glabrata: pathogenicity and resistance mechanisms for adaptation and survival. J Fungi (Basel). 2021;7(8):667. doi:10.3390/jof7080667
  16. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  17. Pierce CG, Uppuluri P, Tristan AR, et al. A simple and reproducible 96-well plate-based method for the formation of fungal biofilms and its application to antifungal susceptibility testing. Nat Protoc. 2008;3(9):1494-1500. doi:10.1038/nport.2008.141
  18. Koutserimpas C, Samonis G, Velivassakis E, Iliopoulou- Kosmadaki S, Kontakis G, Kofteridis DP. Candida glabrata prosthetic joint infection, successfully treated with anidulafungin: a case report and review of the literature. Mycoses. 2018;61(4):266-269. doi:10.1111/myc.12736
  19. Brooks DH, Pupparo F. Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. J Arthroplasty. 1998;13(6):707-712. doi:10.1016/s0883-5403(98)80017-x
  20. Merrer J, Dupont B, Nieszkowska A, De Jonghe B, Outin H. Candida albicans prosthetic arthritis treated with fluconazole alone. J Infect. 2001;42(3):208-209. doi:10.1053/jinf.2001.0819
  21. Koutserimpas C, Naoum S, Alpantaki K, et al. Fungal prosthetic joint infection in revised knee arthroplasty: an orthopaedic surgeon’s nightmare. Diagnostics (Basel). 2022;12(7):1606. doi:10.3390/diagnostics12071606
  22. Gao Z, Li X, Du Y, Peng Y, Wu W, Zhou Y. Success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and potential risk factors of treatment failure: a retrospective study. Med Sci Monit. 2018;24:5549-5557. doi:10.12659/MSM.909168
  23. Hwang BH, Yoon JY, Nam CH, et al. Fungal periprosthetic joint infection after primary total knee replacement. J Bone Joint Surg Br. 2012;94(5):656-659. doi:10.1302/0301-620X.94B5.28125
  24. Ueng SW, Lee CY, Hu CC, Hsieh PH, Chang Y. What is the success of treatment of hip and knee candidal periprosthetic joint infection? Clin Orthop Relat Res. 2013;471(9):3002-3009. doi:10.1007/s11999-013-3007-6
  25. Nodzo, Scott R. MD; Bauer, Thomas MD, PhD; Pottinger, et al. Conventional diagnostic challenges in periprosthetic joint infection. J Am Acad Orthop Surg. 2015;23 Suppl:S18-S25. doi:10.5435/JAAOS-D-14-00385
  26. American Academy of Orthopaedic Surgeons. Diagnosis and prevention of periprosthetic joint infections. March 11, 2019. Accessed February 5, 2025. https://www.aaos.org/pjicpg
References
  1. Osmon DR, Berbari EF, Berendt AR, et al. Executive summary: diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):1-10. doi:10.1093/cid/cis966
  2. Eka A, Chen AF. Patient-related medical risk factors for periprosthetic joint infection of the hip and knee. Ann Transl Med. 2015;3(16):233. doi:10.3978/j.issn.2305-5839.2015.09.26
  3. Darouiche RO, Hamill RJ, Musher DM, Young EJ, Harris RL. Periprosthetic candidal infections following arthroplasty. Rev Infect Dis. 1989;11(1):89-96. doi:10.1093/clinids/11.1.89
  4. Koutserimpas C, Zervakis SG, Maraki S, et al. Non-albicans Candida prosthetic joint infections: a systematic review of treatment. World J Clin Cases. 2019;7(12):1430- 1443. doi:10.12998/wjcc.v7.i12.1430
  5. Fidel PL Jr, Vazquez JA, Sobel JD. Candida glabrata: review of epidemiology, pathogenesis, and clinical disease with comparison to C. albicans. Clin Microbiol Rev. 1999;12(1):80-96. doi:10.1128/CMR.12.1.80
  6. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  7. Lee YR, Kim HJ, Lee EJ, Sohn JW, Kim MJ, Yoon YK. Prosthetic joint infections caused by candida species: a systematic review and a case series. Mycopathologia. 2019;184(1):23-33. doi:10.1007/s11046-018-0286-1
  8. Herndon CL, Rowe TM, Metcalf RW, et al. Treatment outcomes of fungal periprosthetic joint infection. J Arthroplasty. 2023;38(11):2436-2440.e1. doi:10.1016/j.arth.2023.05.009
  9. Delaunay C, Hamadouche M, Girard J, Duhamel A; SoFCOT. What are the causes for failures of primary hip arthroplasties in France? Clin Orthop Relat Res. 2013;471(12): 3863-3869. doi:10.1007/s11999-013-2935-5
  10. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1): 128-133. doi:10.2106/JBJS.H.00155
  11. Furnes O, Lie SA, Espehaug B, Vollset SE, Engesaeter LB, Havelin LI. Hip disease and the prognosis of total hip replacements. A review of 53,698 primary total hip replacements reported to the Norwegian Arthroplasty Register 1987-99. J Bone Joint Surg Br. 2001;83(4):579-586. doi:10.1302/0301-620x.83b4.11223
  12. Gonzalez MR, Bedi ADS, Karczewski D, Lozano-Calderon SA. Treatment and outcomes of fungal prosthetic joint infections: a systematic review of 225 cases. J Arthroplasty. 2023;38(11):2464-2471.e1. doi:10.1016/j.arth.2023.05.003
  13. Gonzalez MR, Pretell-Mazzini J, Lozano-Calderon SA. Risk factors and management of prosthetic joint infections in megaprostheses-a review of the literature. Antibiotics (Basel). 2023;13(1):25. doi:10.3390/antibiotics13010025
  14. Biswas C, Chen SC, Halliday C, et al. Identification of genetic markers of resistance to echinocandins, azoles and 5-fluorocytosine in Candida glabrata by next-generation sequencing: a feasibility study. Clin Microbiol Infect. 2017;23(9):676.e7-676.e10. doi:10.1016/j.cmi.2017.03.014
  15. Hassan Y, Chew SY, Than LTL. Candida glabrata: pathogenicity and resistance mechanisms for adaptation and survival. J Fungi (Basel). 2021;7(8):667. doi:10.3390/jof7080667
  16. Aboltins C, Daffy J, Choong P, Stanley P. Current concepts in the management of prosthetic joint infection. Intern Med J. 2014;44(9):834-840. doi:10.1111/imj.12510
  17. Pierce CG, Uppuluri P, Tristan AR, et al. A simple and reproducible 96-well plate-based method for the formation of fungal biofilms and its application to antifungal susceptibility testing. Nat Protoc. 2008;3(9):1494-1500. doi:10.1038/nport.2008.141
  18. Koutserimpas C, Samonis G, Velivassakis E, Iliopoulou- Kosmadaki S, Kontakis G, Kofteridis DP. Candida glabrata prosthetic joint infection, successfully treated with anidulafungin: a case report and review of the literature. Mycoses. 2018;61(4):266-269. doi:10.1111/myc.12736
  19. Brooks DH, Pupparo F. Successful salvage of a primary total knee arthroplasty infected with Candida parapsilosis. J Arthroplasty. 1998;13(6):707-712. doi:10.1016/s0883-5403(98)80017-x
  20. Merrer J, Dupont B, Nieszkowska A, De Jonghe B, Outin H. Candida albicans prosthetic arthritis treated with fluconazole alone. J Infect. 2001;42(3):208-209. doi:10.1053/jinf.2001.0819
  21. Koutserimpas C, Naoum S, Alpantaki K, et al. Fungal prosthetic joint infection in revised knee arthroplasty: an orthopaedic surgeon’s nightmare. Diagnostics (Basel). 2022;12(7):1606. doi:10.3390/diagnostics12071606
  22. Gao Z, Li X, Du Y, Peng Y, Wu W, Zhou Y. Success rate of fungal peri-prosthetic joint infection treated by 2-stage revision and potential risk factors of treatment failure: a retrospective study. Med Sci Monit. 2018;24:5549-5557. doi:10.12659/MSM.909168
  23. Hwang BH, Yoon JY, Nam CH, et al. Fungal periprosthetic joint infection after primary total knee replacement. J Bone Joint Surg Br. 2012;94(5):656-659. doi:10.1302/0301-620X.94B5.28125
  24. Ueng SW, Lee CY, Hu CC, Hsieh PH, Chang Y. What is the success of treatment of hip and knee candidal periprosthetic joint infection? Clin Orthop Relat Res. 2013;471(9):3002-3009. doi:10.1007/s11999-013-3007-6
  25. Nodzo, Scott R. MD; Bauer, Thomas MD, PhD; Pottinger, et al. Conventional diagnostic challenges in periprosthetic joint infection. J Am Acad Orthop Surg. 2015;23 Suppl:S18-S25. doi:10.5435/JAAOS-D-14-00385
  26. American Academy of Orthopaedic Surgeons. Diagnosis and prevention of periprosthetic joint infections. March 11, 2019. Accessed February 5, 2025. https://www.aaos.org/pjicpg
Issue
Federal Practitioner - 42(3)
Issue
Federal Practitioner - 42(3)
Page Number
134-137
Page Number
134-137
Publications
Federal Practitioner
Publications
Federal Practitioner
Topics
Orthopedics
Hip
Mixed Topics
Article Type
Article
Display Headline

A Candida Glabrata-Associated Prosthetic Joint Infection: Case Report and Literature Review

Display Headline

A Candida Glabrata-Associated Prosthetic Joint Infection: Case Report and Literature Review

Sections
Case Reports
Disallow All Ads
Content Gating
No Gating (article Unlocked/Free)
Alternative CME
Disqus Comments
Default
Gate On Date
Wed, 03/12/2025 - 11:51
Un-Gate On Date
Wed, 03/12/2025 - 11:51
Use ProPublica
CFC Schedule Remove Status
Wed, 03/12/2025 - 11:51
Hide sidebar & use full width
render the right sidebar.
Conference Recap Checkbox
Not Conference Recap
Clinical Edge
Display the Slideshow in this Article
Medscape Article
Display survey writer
Reuters content
Disable Inline Native ads
WebMD Article
survey writer start date
Wed, 03/12/2025 - 11:51
Subscribe to Michelle Seu, MD