Selection of Antifungals in Bone Cements for the Treatment of Fungal Prosthetic Joint Infections - A Systematic Review

Background:Although antibiotic-impregnated bone cement has been widely used for the treatment of bacteria prosthetic joint infections, the use of antifungal-impregnated bone cement (AF-BC) in the treatment of Fungal Prosthetic Joint Infections (F-PJIs) remains unclear. This systematic review aims to summarise the use of AF-BC for the treatment of F-PJIs.

Methods:A literature search was performed using Ovid Medline, Embase, CINHAL and Cochrane via the Ovid platform from inception until August 2023. Screening was performed by two independent reviewers with a third for discrepancies.

Results:Out of 191 articles identified, 25 articles met the inclusion criteria describing 102 joints in which AF-BC was employed. All studies were case reports or case series, and no randomized controlled trials. Majority of the cases were caused by Candida species (95%). Amphotericin B was the preferred antifungal (86%) with a mean dose of 0.37g ± 0.25g per 40g bag of cement but ranged from 0.1-1.2g. Of the 81 cases that achieved infection free survival, the mean time for AF-BC was 25 weeks (range 3-60).

Conclusion:Our systematic review showed that a 2-stage reimplantation approach using AF-BCs combined with systemic antifungal therapy was successful in treating majority of F-PJIs. However, due to the small sample size, specific recommendations regarding the use of antifungal treatment in bone cements cannot be made. The combination of 0.3g of amphotericin B and 1.8g of vancomycin per 40g of bone cement demonstrated successful infection-free survival at the 12-month follow-up in most reported cases.