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Invasive Fungal Infections

Beginning in 2009, physicians at military hospitals that received combat-wounded individuals noted an increasing frequency of blast trauma patients with penetrating wounds sustained in southern Afghanistan diagnosed with the unexpected complication of invasive fungal wound infections (IFIs). These infections are characterized by recurrent wound tissue necrosis and often result in significant morbidity (e.g., limb amputations) and/or mortality. The Infectious Disease Clinical Research Program (IDCRP) at the Uniformed Services University of the Health Sciences (USU) led the Department of Defense outbreak investigation of these cases through their Trauma Infectious Disease Outcomes Study (TIDOS) in conjunction with orthopedic, trauma, and infectious disease services. During periods in 2010-2012, the IFI incidence rates were as high as 10-12% for intensive care unit admissions at Landstuhl Regional Medical Center in Germany (hospital where patients received care after medical evacuation from combat zone prior to transfer back to the United States), coincident with high blast casualty rates.  Based upon information from the initial outbreak investigation, the Joint Trauma System developed clinical practice guidelines (CPG) on IFI prevention and management. TIDOS analyses have since confirmed the independent IFI risk factors cited in the JTS CPG, including blast injuries sustained while on foot patrol, traumatic above knee amputations, and large-volume (>20 units) blood transfusions within first 24 hours after injury. In addition, through collaboration by TIDOS and hospital clinicians, a local CPG was implemented at Landstuhl, which greatly reduced the time to diagnosis and treatment initiation. Furthermore, a recent TIDOS analysis demonstrated the significant negative impact of IFIs on the timing of wound closure and healing. Aggressive surgical debridements remain the primary therapy accompanied by empiric systemic antifungal therapy when there is strong suspicion of an IFI. Other recommendations include: 1) early tissue sampling for wound histopathology and fungal cultures, 2) early consultation with infectious disease specialists and 3) coordination with surgical pathology and clinical microbiology.

Publications

Warkentien TE, Shaikh F, Weintrob AC, Rodriguez CJ, Murray CK, Lloyd BA, Ganesan A, Aggarwal D, Carson ML, and Tribble DR on behalf of the IDCRP TIDOS Group.  Impact of Mucorales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections. Journal of Clinical Microbiology. 2015.

Warkentien T, Rodriguez C, Lloyd B, et al. Invasive Fungal Infections following Combat-related Injuries. Clinical Infectious Diseases. 2012; 55(11):1441-1449.

Rodriguez C, Weintrob AC, Shah J, et al. Risk factors associated with invasive fungal infections in combat trauma. Surgical Infections. 2014; 15(5):521-526.

Lloyd BA, Weintrob AC, Rodriguez C, et al. Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries. Surgical Infections. 2014; 15(5):619-626.

Tribble DR and Rodriguez CJ. Combat-related invasive fungal wound infections. Current Fungal Infection Reports. 2014; 8(4):277-286.

Rodriguez CJ, Weintrob AC, Dunne JR, et al. Clinical Relevance of Mold Culture Positivity With and Without Recurrent Wound Necrosis Following Combat-Related Injuries. Journal of Trauma. 2014; 77(5):769-773.

Weintrob AC, Weisbrod AB, Dunne JR, et al. Combat trauma-associated invasive fungal wound infections: Epidemiology and clinical classification. Epidemiology and Infection. 2015; 143(1):214-224.