Combat-Related Invasive Fungal Wound Infections

ABSTRACT Introduction During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System. Methods In 2011, the Trauma Infectious Disea...

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Published in:Military medicine 2022-05, Vol.187 (Supplement_2), p.34-41
Main Authors: Rodriguez, (Ret.) Carlos J, Ganesan, Anuradha, Shaikh, Faraz, Carson, M Leigh, Bradley, William, Warkentien, Tyler E, Tribble, David R
Format: Article
Language:English
Subjects:
Afghan Campaign 2001
Blast Injuries
Casualties
Classification schemes
Clinical medicine
Communicable Diseases
Epidemiology
Histopathology
Humans
Invasive Fungal Infections - diagnosis
Invasive Fungal Infections - epidemiology
Invasive Fungal Infections - etiology
Laboratories
Military Personnel
Retrospective Studies
Supplement
Trauma
Wound Infection - epidemiology
Wound Infection - microbiology
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Summary:ABSTRACT Introduction During Operation Enduring Freedom in Afghanistan, an outbreak of combat-related invasive fungal wound infections (IFIs) emerged among casualties with dismounted blast trauma and became a priority issue for the Military Health System. Methods In 2011, the Trauma Infectious Disease Outcomes Study (TIDOS) team led the Department of Defense IFI outbreak investigation to describe characteristics of IFIs among combat casualties and provide recommendations related to management of the disease. To support the outbreak investigation, existing IFI definitions and classifications utilized for immunocompromised patients were modified for use in epidemiologic research in a trauma population. Following the conclusion of the outbreak investigation, multiple retrospective analyses using a population of 77 IFI patients (injured during June 2009 to August 2011) were conducted to evaluate IFI epidemiology, wound microbiology, and diagnostics to support refinement of Joint Trauma System (JTS) clinical practice guidelines. Following cessation of combat operations in Afghanistan, the TIDOS database was comprehensively reviewed to identify patients with laboratory evidence of a fungal infection and refine the IFI classification scheme to incorporate timing of laboratory fungal evidence and include categories that denote a high or low level of suspicion for IFI. The refined IFI classification scheme was utilized in a large-scale epidemiologic assessment of casualties injured over a 5.5-year period. Results Among 720 combat casualties admitted to participating hospitals (2009-2014) who had histopathology and/or wound cultures collected, 94 (13%) met criteria for an IFI and 61 (8%) were classified as high suspicion of IFI. Risk factors for development of combat-related IFIs include sustaining a dismounted blast injury, experiencing a traumatic transfemoral amputation, and requiring resuscitation with large-volume (>20 units) blood transfusions. Moreover, TIDOS analyses demonstrated the adverse impact of IFIs on wound healing, particularly with order Mucorales. A polymerase chain reaction (PCR)-based assay to identify filamentous fungi and support earlier IFI diagnosis was also assessed using archived formalin-fixed, paraffin-embedded tissue specimens. Although the PCR-based assay had high specificity (99%), there was low sensitivity (63%); however, sensitivity improved to 83% in tissues collected from sites with angioinvasion. Data obtained from the initial IF
ISSN:0026-4075
1930-613X
DOI:10.1093/milmed/usab074