A Narrative Review of Fungal Periprosthetic Joint Infections of the Hip and Knee: Risk Factors, Microbiological Profiles, and Treatment Challenges.

Abstract

Fungal periprosthetic joint infections (PJIs) are rare but increasingly recognized complications following total joint arthroplasty (TJA). While Candida albicans remains the most common pathogen, non-albicans Candida species and other fungi, such as Aspergillus, have gained prominence. These infections often present with subtle clinical features and affect patients with significant comorbidities or immunosuppression. Compared to bacterial PJIs, fungal infections pose unique diagnostic and therapeutic challenges, including biofilm formation, limited antifungal susceptibility, and protracted treatment courses. This narrative review synthesizes current evidence from research articles and review/metanalysis papers, focusing on fungal PJIs. The literature search encompassed publications from 2015 to 2024, identifying key insights on epidemiology, risk factors, microbiological profiles, diagnostic methods, therapeutic strategies, and outcomes. Both classical references and recent studies addressing emerging diagnostic biomarkers and biofilm-active therapies were included. It was shown that C. albicans remains the primary fungal pathogen in PJIs but non-albicans Candida species and other fungi are associated with more complex clinical scenarios, higher recurrence rates, and reduced infection-free survival. Patients commonly exhibit multiple comorbidities, compromised immune status, and previous prosthetic revisions. Diagnosis is complicated by slow-growing organisms and nonspecific inflammatory markers, prompting interest in novel diagnostics such as alpha-defensin, calprotectin, and next-generation sequencing. Two-stage revision arthroplasty, supplemented by prolonged targeted antifungal therapy, is considered the gold standard for chronic infections, although outcomes remain inferior to bacterial PJIs. Emerging strategies, including antifungal-impregnated beads and biofilm-disrupting agents, may improve local infection control. In conclusion, fungal PJIs constitute a challenging clinical entity demanding tailored diagnostic and therapeutic approaches. Further research into standardized diagnostic criteria, optimized antifungal regimens, biomarker validation, and refined surgical strategies is essential. Multidisciplinary collaboration, enhanced patient optimization, and innovative biofilm-directed therapies hold promise for improving outcomes and reducing the burden of fungal PJIs.