Treatment of Fungal Osteomyelitis with Hardware in Place

Primary Management Strategy

The Infectious Diseases Society of America recommends hardware removal as the standard of care for prosthetic joint or orthopedic hardware infections caused by Candida species, as biofilm formation on implants makes eradication nearly impossible with antifungals alone 1, 2, 3, 4
Device removal should be performed as soon as clinically feasible, with consideration for resection arthroplasty or complete hardware removal 2, 5, 6
For prosthetic joints, a two-stage revision is recommended, with removal and reimplantation separated by 3-6 months and prolonged antifungal therapy 3

The American College of Clinical Pharmacy recommends fluconazole 400 mg (6 mg/kg) daily for 6-12 months as initial therapy for susceptible isolates 1, 2, 3, 4, 8
Echinocandin induction (caspofungin 50-70 mg daily, micafungin 100 mg daily, or anidulafungin 100 mg daily) for at least 2 weeks, followed by fluconazole 400 mg daily for 6-12 months, is recommended for critically ill patients or suspected resistance 3, 4, 7, 8

Lifelong fluconazole suppression at 400 mg (6 mg/kg) daily is necessary if the prosthetic device or hardware must remain in place 1, 2, 3, 4, 5, 6, 9

The Infectious Diseases Society of America recommends obtaining tissue biopsy and culture from infected bone before initiating therapy to document mixed bacterial-fungal infections and guide concurrent antibacterial therapy 3, 4, 7, 8

Surgical debridement is essential even with hardware removal, particularly for vertebral osteomyelitis with neurological deficits, spinal instability, large abscesses, or persistent symptoms 3, 4, 8

Repeat cultures after 2 weeks of therapy to document microbiological clearance, and monitor clinical response and inflammatory markers (ESR, CRP) 7
Continue therapy until complete resolution of all signs and symptoms, which typically requires the full 6-12 month course 7, 8