Risk Factors Of Fungal Prosthetic Infection After Knee And Hip Arthroplasty

BackgroundTotal joint arthroplasty(TJA)is a rapid and effective method commonly used in the department of orthopedics to relieve joint pain,improve the line of lower limb,reconstruct joint function and treat end-stage joint disease.It can restore mobility and quality of life for patients with severe joint pain and limited function.Fungal prosthetic infection(PJI)is the most serious and intractable complication after TJA.It causes patients to have a negative impact on the expected outcome of TJA,significantly reduces patients’ satisfaction with the surgery,and increases the readmission rate and mortality at the same time.Fungal PJI accounts for only 1% of all PJI patients.It is not only a catastrophic health problem for patients,but also a serious economic problem due to the increase of total cost before and after the diagnosis and treatment of fungal PJI.In addition,the treatment of fungal PJI is not easy,which requires long-term application of antifungal drugs and multiple operations.In severe cases,it will eventually lead to joint fusion,amputation and even death.In recent years,there is no standard guideline for the prevention,diagnosis and treatment of fungal PJI at home and abroad.In order to evaluate the changeable and unchangeable risk factors of fungal PJI,it is very important to identify potentially changeable risk factors so as to reduce the risk of fungal PJI.ObjectiveTo analyze the risk factors of fungal infection around the prosthesis after knee and hip arthroplasty.MethodsA retrospective analysis was conducted on 19 cases of fungal PJI transferred from the people’s Hospital of Zhengzhou University from June 2016 to July 2020 were used as the fungal PJI group,and 57 cases of bacterial PJI were collected with the same ratio of knee to hip were classified as bacterial PJI group.The clinical data of fungal PJI group and bacterial PJI group were compared: age,gender,body mass index(BMI),smoking history,drinking history,hospitalization time,blood transfusion history,erythrocyte sedimentation rate(ESR),serum C-reactive protein(CRP),D-dimer(D-D),albumin levels;previous comorbidities: cardiovascular system diseases,endocrine system diseases,digestive system diseases,respiratory system diseases,immune system diseases;evaluation indexes: Charlson comorbidity index,(CCI);the number of previous intra-articular puncture,the use of antibiotics after the diagnosis of PJI,the history of hormone use,etc.The difference between the two groups was analyzed by relevant statistical methods.P < 0.05 indicated that the difference was statistically significant.The risk factors of fungal PJI after knee and hip arthroplasty were analyzed by logistic regression analysis.Results(1)The length of hospital stay in fungal PJI Group [20(13.00,24.00)d] was longer than that in bacterial PJI Group [14(11.00,24.00)d],The rates of ≥ 3 kinds of basic diseases,CCI score ≥ 3 points,intra-articular puncture ≥ 3 times,and antibiotics use ≥ 3 kinds after the diagnosis of PJI(84.21%,89.47%,84.21%,89.47%)were higher than those of bacterial PJI group(43.86%,49.12%,50.88%,64.91%)(P < 0.05);There was no significant differences in the levels of the age,BMI,male ratio,blood transfusion history ratio and long-term hormone use ratio,albumin < 30g/L ritio,CRP,ESR and D-D levels in fungal PJI group compared with those of bacterial PJI group(P > 0.05);(2)By analyzing the distribution of pathogenic bacteria in bacterial PJI group and fungal PJI group,59 bacterial strains in bacterial PJI group and 22 fungal strains were found in the fungal group.There were 20 strains of staphylococcus aureus in the bacterial PJI group,accounting for the highest proportion(33.90%),followed by16 strains of staphylococcus epidermidis(27.12%),6 strains of Escherichia coli(10.17%),4 strains of pseudomonas aeruginosa(6.78%),4 strains of Staphylococcus haemolyticus(6.78%),2 strains of klebsiella pneumoniae(3.39%),2 strains of enterobacter cloacae(3.39%)and 1 strain of Streptococcus constellation(1.69%),etc.The fungal PJI group has the highest proportion of candida albicans with 9 strains(40.91%),5 strains of candida parapsilosis(22.73%),4 strains of candida glabrata(18.19%),abnormal Wickham’s yeast 2 strains of bacteria(9.09%),1 strain of Candida tropicalis(4.55%),etc;(3)Univariate regression analysis showed that there were more than 3 basic diseases(OR = 6.827,95% CI 1.788-26.059,P = 0.005),CCI score ≥ 3(OR =8.804,95% CI 1.860-41.663,P = 0.006),and intra-articular puncture ≥ 3 times(OR =5.149,95% CI 1.351-19.627,P = 0.006)are the factors for fungal PJI after knee and hip arthroplasty;(4)The results of multivariate regression analysis showed that there were more than 3 kinds of basic diseases(OR = 5.916,95% CI 1.215-28.813,P = 0.028),CCI score ≥ 3(OR = 6.111,95% CI 1.071-34.867,P = 0.042)and intra-articular puncture≥ 3 times(OR = 8.327,95% CI 1.686-41.111,P = 0.009)was the risk factor of fungal PJI after total knee and hip arthroplasty(P < 0.05).Conclusion(1)Bacterial PJI is mainly caused by Staphylococcus aureus,and Candida albicans is the main strain in fungal PJI;(2)The risk of fungal PJI is related to a variety of factors,and the occurrence of fungal PJI is the result of the combined effect of these independent risk factors;(3)Combined with a variety of basic diseases,high CCI score and previous multiple arthrocentesis history,and are the risk factors of fungal PJI.