Hip Int 2014; 24 ( 6): 656-659
DOI: 10.5301/hipint.5000205
CASE REPORT
Acremonium species combined with Penicillium species infection in hip hemiarthroplasty: a case report and literature review Cheng-Yi Wu1, Hui-Kuang Huang1,3-5, Po-Kuei Wu2-4, Wei-Ming Chen3,4, Mei-Chu Lai6, Lien-Hsiang Chung1-4 Division of Orthopaedic Oncology, Orthopaedic Department, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City - Taiwan 2 Institute of Clinical Medicine, National Yang-Ming University, Taipei - Taiwan 3 Department of Orthopaedics and Joint Reconstruction, Taipei Veterans General Hospital, Taipei - Taiwan 4 Department of Orthopaedic Surgery, School of Medicine, National Yang-Ming University, Taipei - Taiwan 5 Chung Hwa University of Medical Technology, Chia-Yi - Taiwan 6 Department of Laboratory Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi - Taiwan 1
Objective: To illustrate that Acremonium and Penicillium species are being increasingly recognised in periprosthetic joint infections (PJIs). Case Report: A 47-year-old male with liver cirrhosis and bilateral hip hemiarthroplasties complained of persistent right hip pain. Bone scan was suspicious for right hip septic arthritis. Laboratory studies revealed an elevated erythrocyte sedimentation rate (ESR; 127 mm/h) and C-reactive protein (CRP; 16.171 mg/L). At surgery caseous necrosis with a yellowish appearance around the hip was noted. Intraoperative cultures were positive for Acremonium and Penicillium species 2 weeks after inoculation. After 4 months of fluconazole monotherapy a successful revision right total hip arthroplasty was performed, the patient is walking without assistance at 1 year after surgery. Conclusions: We reported a prosthetic hip infection due to Acremonium and Penicillium species. Removal of the prosthesis, antifungal therapy, and re-implantation after 4 months were successful. Keywords: Acremonium species, Penicillium species, Fungus infection, Hip hemiarthroplasty, First case report Accepted: October 7, 2014
Introduction Periprosthetic joint infection (PJI) is one of the most dreaded and complex complications after total joint arthroplasty. The majority of infections are caused by Grampositive bacteria, especially Staphylococcus species (1). The number of fungal PJIs has increased over the past 10 years, and now represents about 1% of orthopaedic prosthesis infections (2). We have noted a recent upsurge in hyaline filamentous fungi, which previously did not 656
have pathogenic properties, involved in serious and invasive diseases. Acremonium, a genus of saprobic fungi found in soil, plants, and insects, is an uncommon cause of disease in humans. Penicillium is a genus of ascomycetous fungi of major importance in the natural environment as well as food and drug production. It is commonly considered a contaminant, but is found in a variety of diseases in which its aetiologic significance is uncertain. Penicillium species have also been known to cause corneal, cutaneous, external ear, and urinary tract infections.
© 2014 Wichtig Publishing - ISSN 1120-7000
Wu et al
Fig. 1 - At admission erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both elevated (127 mm/h and 16.171 mg/L, respectively). Fluconazole monotherapy (450 mg/day orally) was administered, and a gradual decrease of ESR and CRP levels were seen.
Herein, we report a case in which a PJI after right hip hemiarthroplasty was due to Acremonium combined with Penicillium species.
Case report A 47-year-old male with liver cirrhosis due to chronic hepatitis virus B (HBV) infection, and a Child-Pugh score grade B for more than 10 years underwent bilateral hip bipolar hemiarthroplasties in 2002 at another institute. Approximately 10 years after the index surgery, the patient complained of intermittent fever and persistent right hip pain with loss of the ability to ambulate for 1 month and was admitted to our ward via the emergency department. At admission, the patient was afebrile and physical examination revealed tender swelling of the right hip and painful range of motion in all directions. The Harris Hip Score was 24 initially. Laboratory parameters disclosed a white blood cell (WBC) count of 6860/mm3 (62.1% neutrophils and 28.4% lymphocytes), an elevated erythrocyte sedimentation rate (ESR; 127 mm/h) and elevated C-reactive protein (CRP; 16.171 mg/L (Fig. 1)). Preoperative blood culture showed negative findings for bacteraemia or fungaemia. Radiography of the right hip showed no signs of implant loosening (Fig. 2A), and bone scan was suspicious for septic arthritis. Abdominal computed tomography (CT) and echocardiography were negative for evidence of infection. Ultrasound-guided hip aspiration was attempted, but failed. The patient was treated with empiric antibiotic therapy (ceftriaxone and vancomycin), but the pain persisted. Admission blood cultures were negative for bacteria and fungi.
After discussions with the patient, surgical intervention was scheduled. Antibiotics were discontinued 1 week before surgery to improve the validity of intraoperative cultures. At surgery, caseous necrosis with a yellowish appearance was noted confined in the hip joint and mainly present over the acetabulum and joint capsule. Invasion into the femoral canal was not noted intraoperatively. The acetabular shell and head were removed with retention of the well-fixed stem, and a 1 gm vancomycin-loaded cement spacer was implanted after extensive debridement (Fig. 2B). The specimens collected intraoperatively were Gram stain negative. Intraoperative fungals cultures grew moderate Acremonium and Penicillium species after 2 weeks of incubation (Fig. 3). Infectious disease consultation recommended fluconazole monotherapy (450 mg/day orally) for 12 weeks. Protective weight bearing with walker was allowed postoperatively. After 4 months a successful revision right total hip arthroplasty (THA) was performed. The Harris Hip Score improved from 24 on initial admission to 89 at 1 year of follow-up. The patient could walk without assistance, with complete pain relief, and a flexion range >90°. Radiography showed a well-aligned total hip prosthesis with no signs of implant loosening (Fig. 2C), and laboratory evaluation disclosed an ESR of 34 mm/h and CRP of 0.313 mg/L (Fig. 1). The patient has been continued on maintenance fluconazole (450 mg/day) indefinitely for 12 months.
Discussion A steady increase in hyaline fungi incriminated as opportunistic pathogens has been seen in the past 2 decades. Many
© 2014 Wichtig Publishing - ISSN 1120-7000
657
Acremonium combined with Penicillium infection in hip hemiarthroplasty
Fig. 2 - Radiographs of the right hip: A) preoperatively no signs of prosthesis loosening were present; B) right hip after extensive debridement and removal of the cup shell and head with retention of the well-fixed stem, and implantation of a vancomycinloaded cement spacer; C) at 1-year postoperatively after THA the hip prosthesis is well-aligned with no signs of implant loosening.
Fig. 3 - Macroscopical characters of Acremonium and Penicillium on agar media: A) colony morphology of Acremonium was at first compact and glabrous, and white, yellowish, light gray, or pale rose in color; B) reverse side of the Acremonium was colorless, pale yellow, or pinkish; C) colony morphology of Penicillium species at the surface is white, and then becomes very powdery and bluish green with a white border; D) reverse side of Penicillium species is usually white, but may be red; E) microscopic morphology of Penicillium species forming the characteristic “penicillus” or “brush” appearance; F) microscopic morphology of Acremonium showing septate hyphae with unbranched and erect phialides, and the conidia form easily disrupted clusters at the tips of the phialides.
soil saprobes and plant pathogens with no obvious pathogenic potential have now emerged as aetiologic agents in a variety of clinical conditions. Acremonium and Penicillium species are being increasingly recognised as aetiological agents in both localised and systemic infections. Host factors appear to play an important role in the development of invasive fungal infections. At least 1 underlying condition, including immunosuppression, malignancy, diabetes mellitus, corticosteroid use, and intravenous drug use (3, 4), was identified in 89% of patients with THA infections (5). A preceding bacterial infection of the prosthesis can also be a risk factor for subsequent fungal infection (6). In our case, liver cirrhosis and chronic HBV infection was the identified host factor. The exact mechanism of fungal PJI is not clear. The infection most likely results from the inoculation of skin microflora at the time of penetrating injury or implantation (7). Signs of infection usually appear rapidly (less than 658
4 weeks) after the procedure. In our case, infection occurred more than 10 years after the index surgery, and the 2 species were collected from the intraoperative aseptic environment; thus, not likely the result of contamination. Therefore, a haematogenous route following unrecognised fungaemia is a more likely cause. The diagnosis of a fungal PJI can be challenging. The standard biological markers (leukocytes, ESR, CRP) provide little information. The diagnosis is normally established by positive cultures from multiple joint aspirations, or from a tissue specimen at the time of surgery. Cultures should not be considered negative for growth until 4 weeks after inoculation (5). Acikgoz et al (8) reported that fungi were not detected in any tissue sample until scrapings from the surface of the explanted prosthesis were examined. There are no standard therapies for PJIs caused by Acremonium. Management typically consists of surgery (mostly removal and re-implantation of the prosthesis in 2 stages
© 2014 Wichtig Publishing - ISSN 1120-7000
Wu et al
separated by 3 to 6 months), and a long period of antifungal therapy (9). For antifungal treatment of native joint infections, recent guidelines suggest the use of an initial course of amphotericin B for 2 to 3 weeks, followed by fluconazole for a total of 6 to 12 weeks of treatment (10). Amphotericin B has been shown to be the most effective drug (11), followed by itraconazole and ketoconazole (12). In our case, we combined partial resection of the prosthesis and a 4-month delay in performing revision THA and a prolonged course (12 months) of fluconazole. In conclusion, we report a prosthetic hip infection due to Acremonium and Penicillium species. Removal of the
References 1.
Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis. 2003;36(9):1157-1161. 2. Kojic EM, Darouiche RO. Candida infections of medical devices. Clin Microbiol Rev. 2004;17(2):255-267. 3. Cardinal E, Braunstein EM, Capello WN, Heck DA. Candida albicans infection of prosthetic joints. Orthopedics. 1996; 19(3):247-251. 4. Hennessy MJ. Infection of a total knee arthroplasty by Candida parapsilosis. A case report of successful treatment by joint reimplantation with a literature review. Am J Knee Surg. 1996; 9(3):133-136. 5. Azzam K, Parvizi J, Jungkind D, et al. Microbiological, clinical, and surgical features of fungal prosthetic joint infections: a multi-institutional experience. J Bone Joint Surg Am. 2009; 91(Suppl 6):142-149. 6. Kelesidis T, Tsiodras S. Candida albicans prosthetic hip infection in elderly patients: is fluconazole monotherapy an option? Scand J Infect Dis. 2010;42(1):12-21. 7. Legout L, Assal M, Rohner P, Lew D, Bernard L, Hoffmeyer P. Successful treatment of Candida parapsilosis (fluconazoleresistant) osteomyelitis with caspofungin in a HIV patient. Scand J Infect Dis. 2006;38(8):728-730. 8. Açikgöz ZC, Sayli U, Avci S, Dog˘ruel H, Gamberzade S. An extremely uncommon infection: Candida glabrata arthritis
prosthesis, antifungal therapy, and re-implantation after 4 months was successful in this case. Financial Support: None. Conflict of Interest: None. Address for correspondence: Lien-Hsiang Chung Orthopaedic Department Ditmanson Medical Foundation Chia-Yi Christian Hospital 539 Jhongsiao Rd. Chia-Yi City, Taiwan [email protected]
after total knee arthroplasty. Scand J Infect Dis. 2002;34(5): 394-396. 9. Spilf O; Société de Pathologie Infectieuse de Langue Française (SPILF); Collège des Universitaires de Maladies Infectieuses et Tropicales (CMIT); Groupe de Pathologie Infectieuse Pédiatrique (GPIP); Société Française d’Anesthésie et de Réanimation (SFAR); Société Française de Chirurgie Orthopédique et Traumatologique (SOFCOT); Société Française d’Hygiène Hospitalière (SFHH); Société Française de Médecine Nucléaire (SFMN); Société Française de Médecine Physique et de Réadaptation (SOFMER); Société Française de Microbiologie (SFM); Société Française de Radiologie (SFRRad); Société Française de Rhumatologie (SFR-Rhu). Recommendations for bone and joint prosthetic device infections in clinical practice (prosthesis, implants, osteosynthesis). Société de Pathologie Infectieuse de Langue Française. Med Mal Infect. 2010;40(4):185-211. 10. Hanssen AD, Rand JA. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect. 1999;48:111-122. 11. Beaudreuil S, Buchler M, Al Najjar A, et al. Acute septic arthritis after kidney transplantation due to Acremonium. Nephrol Dial Transplant. 2003;18(4):850-851. 12. Guarro J, Gams W, Pujol I, Gené J. Acremonium species: new emerging fungal opportunists—in vitro antifungal susceptibilities and review. Clin Infect Dis. 1997;25(5):1222-1229. Accepted: October 7, 2014
© 2014 Wichtig Publishing - ISSN 1120-7000
659
Copyright of Hip International is the property of Wichtig International Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
DOI: 10.5301/hipint.5000205
CASE REPORT
Acremonium species combined with Penicillium species infection in hip hemiarthroplasty: a case report and literature review Cheng-Yi Wu1, Hui-Kuang Huang1,3-5, Po-Kuei Wu2-4, Wei-Ming Chen3,4, Mei-Chu Lai6, Lien-Hsiang Chung1-4 Division of Orthopaedic Oncology, Orthopaedic Department, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City - Taiwan 2 Institute of Clinical Medicine, National Yang-Ming University, Taipei - Taiwan 3 Department of Orthopaedics and Joint Reconstruction, Taipei Veterans General Hospital, Taipei - Taiwan 4 Department of Orthopaedic Surgery, School of Medicine, National Yang-Ming University, Taipei - Taiwan 5 Chung Hwa University of Medical Technology, Chia-Yi - Taiwan 6 Department of Laboratory Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi - Taiwan 1
Objective: To illustrate that Acremonium and Penicillium species are being increasingly recognised in periprosthetic joint infections (PJIs). Case Report: A 47-year-old male with liver cirrhosis and bilateral hip hemiarthroplasties complained of persistent right hip pain. Bone scan was suspicious for right hip septic arthritis. Laboratory studies revealed an elevated erythrocyte sedimentation rate (ESR; 127 mm/h) and C-reactive protein (CRP; 16.171 mg/L). At surgery caseous necrosis with a yellowish appearance around the hip was noted. Intraoperative cultures were positive for Acremonium and Penicillium species 2 weeks after inoculation. After 4 months of fluconazole monotherapy a successful revision right total hip arthroplasty was performed, the patient is walking without assistance at 1 year after surgery. Conclusions: We reported a prosthetic hip infection due to Acremonium and Penicillium species. Removal of the prosthesis, antifungal therapy, and re-implantation after 4 months were successful. Keywords: Acremonium species, Penicillium species, Fungus infection, Hip hemiarthroplasty, First case report Accepted: October 7, 2014
Introduction Periprosthetic joint infection (PJI) is one of the most dreaded and complex complications after total joint arthroplasty. The majority of infections are caused by Grampositive bacteria, especially Staphylococcus species (1). The number of fungal PJIs has increased over the past 10 years, and now represents about 1% of orthopaedic prosthesis infections (2). We have noted a recent upsurge in hyaline filamentous fungi, which previously did not 656
have pathogenic properties, involved in serious and invasive diseases. Acremonium, a genus of saprobic fungi found in soil, plants, and insects, is an uncommon cause of disease in humans. Penicillium is a genus of ascomycetous fungi of major importance in the natural environment as well as food and drug production. It is commonly considered a contaminant, but is found in a variety of diseases in which its aetiologic significance is uncertain. Penicillium species have also been known to cause corneal, cutaneous, external ear, and urinary tract infections.
© 2014 Wichtig Publishing - ISSN 1120-7000
Wu et al
Fig. 1 - At admission erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both elevated (127 mm/h and 16.171 mg/L, respectively). Fluconazole monotherapy (450 mg/day orally) was administered, and a gradual decrease of ESR and CRP levels were seen.
Herein, we report a case in which a PJI after right hip hemiarthroplasty was due to Acremonium combined with Penicillium species.
Case report A 47-year-old male with liver cirrhosis due to chronic hepatitis virus B (HBV) infection, and a Child-Pugh score grade B for more than 10 years underwent bilateral hip bipolar hemiarthroplasties in 2002 at another institute. Approximately 10 years after the index surgery, the patient complained of intermittent fever and persistent right hip pain with loss of the ability to ambulate for 1 month and was admitted to our ward via the emergency department. At admission, the patient was afebrile and physical examination revealed tender swelling of the right hip and painful range of motion in all directions. The Harris Hip Score was 24 initially. Laboratory parameters disclosed a white blood cell (WBC) count of 6860/mm3 (62.1% neutrophils and 28.4% lymphocytes), an elevated erythrocyte sedimentation rate (ESR; 127 mm/h) and elevated C-reactive protein (CRP; 16.171 mg/L (Fig. 1)). Preoperative blood culture showed negative findings for bacteraemia or fungaemia. Radiography of the right hip showed no signs of implant loosening (Fig. 2A), and bone scan was suspicious for septic arthritis. Abdominal computed tomography (CT) and echocardiography were negative for evidence of infection. Ultrasound-guided hip aspiration was attempted, but failed. The patient was treated with empiric antibiotic therapy (ceftriaxone and vancomycin), but the pain persisted. Admission blood cultures were negative for bacteria and fungi.
After discussions with the patient, surgical intervention was scheduled. Antibiotics were discontinued 1 week before surgery to improve the validity of intraoperative cultures. At surgery, caseous necrosis with a yellowish appearance was noted confined in the hip joint and mainly present over the acetabulum and joint capsule. Invasion into the femoral canal was not noted intraoperatively. The acetabular shell and head were removed with retention of the well-fixed stem, and a 1 gm vancomycin-loaded cement spacer was implanted after extensive debridement (Fig. 2B). The specimens collected intraoperatively were Gram stain negative. Intraoperative fungals cultures grew moderate Acremonium and Penicillium species after 2 weeks of incubation (Fig. 3). Infectious disease consultation recommended fluconazole monotherapy (450 mg/day orally) for 12 weeks. Protective weight bearing with walker was allowed postoperatively. After 4 months a successful revision right total hip arthroplasty (THA) was performed. The Harris Hip Score improved from 24 on initial admission to 89 at 1 year of follow-up. The patient could walk without assistance, with complete pain relief, and a flexion range >90°. Radiography showed a well-aligned total hip prosthesis with no signs of implant loosening (Fig. 2C), and laboratory evaluation disclosed an ESR of 34 mm/h and CRP of 0.313 mg/L (Fig. 1). The patient has been continued on maintenance fluconazole (450 mg/day) indefinitely for 12 months.
Discussion A steady increase in hyaline fungi incriminated as opportunistic pathogens has been seen in the past 2 decades. Many
© 2014 Wichtig Publishing - ISSN 1120-7000
657
Acremonium combined with Penicillium infection in hip hemiarthroplasty
Fig. 2 - Radiographs of the right hip: A) preoperatively no signs of prosthesis loosening were present; B) right hip after extensive debridement and removal of the cup shell and head with retention of the well-fixed stem, and implantation of a vancomycinloaded cement spacer; C) at 1-year postoperatively after THA the hip prosthesis is well-aligned with no signs of implant loosening.
Fig. 3 - Macroscopical characters of Acremonium and Penicillium on agar media: A) colony morphology of Acremonium was at first compact and glabrous, and white, yellowish, light gray, or pale rose in color; B) reverse side of the Acremonium was colorless, pale yellow, or pinkish; C) colony morphology of Penicillium species at the surface is white, and then becomes very powdery and bluish green with a white border; D) reverse side of Penicillium species is usually white, but may be red; E) microscopic morphology of Penicillium species forming the characteristic “penicillus” or “brush” appearance; F) microscopic morphology of Acremonium showing septate hyphae with unbranched and erect phialides, and the conidia form easily disrupted clusters at the tips of the phialides.
soil saprobes and plant pathogens with no obvious pathogenic potential have now emerged as aetiologic agents in a variety of clinical conditions. Acremonium and Penicillium species are being increasingly recognised as aetiological agents in both localised and systemic infections. Host factors appear to play an important role in the development of invasive fungal infections. At least 1 underlying condition, including immunosuppression, malignancy, diabetes mellitus, corticosteroid use, and intravenous drug use (3, 4), was identified in 89% of patients with THA infections (5). A preceding bacterial infection of the prosthesis can also be a risk factor for subsequent fungal infection (6). In our case, liver cirrhosis and chronic HBV infection was the identified host factor. The exact mechanism of fungal PJI is not clear. The infection most likely results from the inoculation of skin microflora at the time of penetrating injury or implantation (7). Signs of infection usually appear rapidly (less than 658
4 weeks) after the procedure. In our case, infection occurred more than 10 years after the index surgery, and the 2 species were collected from the intraoperative aseptic environment; thus, not likely the result of contamination. Therefore, a haematogenous route following unrecognised fungaemia is a more likely cause. The diagnosis of a fungal PJI can be challenging. The standard biological markers (leukocytes, ESR, CRP) provide little information. The diagnosis is normally established by positive cultures from multiple joint aspirations, or from a tissue specimen at the time of surgery. Cultures should not be considered negative for growth until 4 weeks after inoculation (5). Acikgoz et al (8) reported that fungi were not detected in any tissue sample until scrapings from the surface of the explanted prosthesis were examined. There are no standard therapies for PJIs caused by Acremonium. Management typically consists of surgery (mostly removal and re-implantation of the prosthesis in 2 stages
© 2014 Wichtig Publishing - ISSN 1120-7000
Wu et al
separated by 3 to 6 months), and a long period of antifungal therapy (9). For antifungal treatment of native joint infections, recent guidelines suggest the use of an initial course of amphotericin B for 2 to 3 weeks, followed by fluconazole for a total of 6 to 12 weeks of treatment (10). Amphotericin B has been shown to be the most effective drug (11), followed by itraconazole and ketoconazole (12). In our case, we combined partial resection of the prosthesis and a 4-month delay in performing revision THA and a prolonged course (12 months) of fluconazole. In conclusion, we report a prosthetic hip infection due to Acremonium and Penicillium species. Removal of the
References 1.
Lentino JR. Prosthetic joint infections: bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis. 2003;36(9):1157-1161. 2. Kojic EM, Darouiche RO. Candida infections of medical devices. Clin Microbiol Rev. 2004;17(2):255-267. 3. Cardinal E, Braunstein EM, Capello WN, Heck DA. Candida albicans infection of prosthetic joints. Orthopedics. 1996; 19(3):247-251. 4. Hennessy MJ. Infection of a total knee arthroplasty by Candida parapsilosis. A case report of successful treatment by joint reimplantation with a literature review. Am J Knee Surg. 1996; 9(3):133-136. 5. Azzam K, Parvizi J, Jungkind D, et al. Microbiological, clinical, and surgical features of fungal prosthetic joint infections: a multi-institutional experience. J Bone Joint Surg Am. 2009; 91(Suppl 6):142-149. 6. Kelesidis T, Tsiodras S. Candida albicans prosthetic hip infection in elderly patients: is fluconazole monotherapy an option? Scand J Infect Dis. 2010;42(1):12-21. 7. Legout L, Assal M, Rohner P, Lew D, Bernard L, Hoffmeyer P. Successful treatment of Candida parapsilosis (fluconazoleresistant) osteomyelitis with caspofungin in a HIV patient. Scand J Infect Dis. 2006;38(8):728-730. 8. Açikgöz ZC, Sayli U, Avci S, Dog˘ruel H, Gamberzade S. An extremely uncommon infection: Candida glabrata arthritis
prosthesis, antifungal therapy, and re-implantation after 4 months was successful in this case. Financial Support: None. Conflict of Interest: None. Address for correspondence: Lien-Hsiang Chung Orthopaedic Department Ditmanson Medical Foundation Chia-Yi Christian Hospital 539 Jhongsiao Rd. Chia-Yi City, Taiwan [email protected]
after total knee arthroplasty. Scand J Infect Dis. 2002;34(5): 394-396. 9. Spilf O; Société de Pathologie Infectieuse de Langue Française (SPILF); Collège des Universitaires de Maladies Infectieuses et Tropicales (CMIT); Groupe de Pathologie Infectieuse Pédiatrique (GPIP); Société Française d’Anesthésie et de Réanimation (SFAR); Société Française de Chirurgie Orthopédique et Traumatologique (SOFCOT); Société Française d’Hygiène Hospitalière (SFHH); Société Française de Médecine Nucléaire (SFMN); Société Française de Médecine Physique et de Réadaptation (SOFMER); Société Française de Microbiologie (SFM); Société Française de Radiologie (SFRRad); Société Française de Rhumatologie (SFR-Rhu). Recommendations for bone and joint prosthetic device infections in clinical practice (prosthesis, implants, osteosynthesis). Société de Pathologie Infectieuse de Langue Française. Med Mal Infect. 2010;40(4):185-211. 10. Hanssen AD, Rand JA. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. Instr Course Lect. 1999;48:111-122. 11. Beaudreuil S, Buchler M, Al Najjar A, et al. Acute septic arthritis after kidney transplantation due to Acremonium. Nephrol Dial Transplant. 2003;18(4):850-851. 12. Guarro J, Gams W, Pujol I, Gené J. Acremonium species: new emerging fungal opportunists—in vitro antifungal susceptibilities and review. Clin Infect Dis. 1997;25(5):1222-1229. Accepted: October 7, 2014
© 2014 Wichtig Publishing - ISSN 1120-7000
659
Copyright of Hip International is the property of Wichtig International Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
