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Geringer MR, Stewart L, Shaikh F, Carson ML, Lu D, Cancio LC, Gurney JM, Tribble DR, Kiley JL. Epidemiology and timing of infectious complications from battlefield-related burn injuries. Burns 2024:S0305-4179(24)00204-3. [PMID: 39341778 DOI: 10.1016/j.burns.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/28/2024] [Accepted: 07/04/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Infections are the most frequent complication and cause of mortality in burn patients. We describe the epidemiology and outcomes of infections among deployed U.S. military personnel with burns. METHODS Military personnel who sustained a burn injury in Iraq or Afghanistan (2009-2014) and were admitted to the Burn Center at U.S. Army Institute of Surgical Research at Brooke Army Medical Center were included in the analysis. RESULTS The study population included 144 patients who were primarily young (median 24 years) males (99 %) with combat-related burns (62 %) sustained via a blast (57 %), resulting in a median total body surface area burned (TBSA) of 6 % (IQR 3-14 %). Twenty-six (18 %) patients developed infections, with pneumonia being the predominant initial infection (= 16), followed by skin and soft-tissue infections (SSTI, = 6), bloodstream infections (BSI, = 3), and intra-abdominal infections (IAI, = 1). Initial infections were diagnosed at a median of 4 days (IQR 3-5) post-injury for pneumonia, 7 days (IQR 4-12) for SSTIs, 7 days (IQR 6-7) for BSI, and 17 days for IAI. Patients with infections were more severely injured with greater TBSA (median 31 % vs 5 %), more inhalation injury (38 % vs 12 %), and longer time to definitive surgical management (median of 34 days vs 9) compared to those who did not develop infections (p < 0.001). Among patients with inhalation injury, a higher proportion developed pneumonia (42 %) compared to those without inhalation injury (5 %; p < 0.001). Five patients developed an invasive fungal infection. Gram-negative bacilli were most frequently recovered, with 32 % of Gram-negative isolates being multidrug-resistant. Four patients died, of whom all had ≥ 4 infections. CONCLUSIONS Military personnel with burn injuries who developed infections were more severely injured with greater TBSA and inhalation injury. Improved understanding of risk factors for burn-related infections in combat casualties is critical for effective management.
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Affiliation(s)
- Matthew R Geringer
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, United States.
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Leopoldo C Cancio
- US. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States
| | - Jennifer M Gurney
- US. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States; Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - John L Kiley
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, United States
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El Eid R, Chowdhary A, El Zakhem A, Kanj SS. Invasive fungal infections in wars, following explosives and natural disasters: A narrative review. Mycoses 2024; 67:e13762. [PMID: 38951663 DOI: 10.1111/myc.13762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/31/2024] [Accepted: 06/22/2024] [Indexed: 07/03/2024]
Abstract
Infections are well-known complications in patients following traumatic injuries, frequently leading to high morbidity and mortality. In particular, trauma occurring in disaster settings, both natural and man-made, such as armed conflicts and explosives detonation, results in challenging medical conditions that impede the best management practices. The incidence of invasive fungal infections (IFI) is increasing in trauma patients who lack the typical risk factors like an immune compromised state or others. This narrative review will focus on IFI as a direct complication after natural disasters, wars, and man-made mass destruction with a summary of the available evidence about the epidemiology, clinical manifestations, risk factors, microbiology, and proper management. In this setting, the clinical manifestations of IFI may include skin and soft tissue infections, osteomyelitis, visceral infections, and pneumonia. IFI should be considered in the war inflicted patients who are exposed to unsterile environments or have wounds contaminated with soil and decaying organic matter.
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Affiliation(s)
| | - Anuradha Chowdhary
- Medical Mycology Unit, Department of Microbiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
- National Reference Laboratory for Antimicrobial Resistance in Fungal Pathogens, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Aline El Zakhem
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
- Center for Infectious Diseases Research (CIDR), American University of Beirut Medical Center, Beirut, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
- Center for Infectious Diseases Research (CIDR), American University of Beirut Medical Center, Beirut, Lebanon
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Thanapaul RJRS, Alamneh YA, Finnegan DK, Antonic V, Abu-Taleb R, Czintos C, Boone D, Su W, Sajja VS, Getnet D, Roberds A, Walsh TJ, Bobrov AG. Development of a Combat-Relevant Murine Model of Wound Mucormycosis: A Platform for the Pre-Clinical Investigation of Novel Therapeutics for Wound-Invasive Fungal Diseases. J Fungi (Basel) 2024; 10:364. [PMID: 38786719 PMCID: PMC11122444 DOI: 10.3390/jof10050364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Wound-invasive fungal diseases (WIFDs), especially mucormycosis, have emerged as life-threatening infections during recent military combat operations. Many combat-relevant fungal pathogens are refractory to current antifungal therapy. Therefore, animal models of WIFDs are urgently needed to investigate new therapeutic solutions. Our study establishes combat-relevant murine models of wound mucormycosis using Rhizopus arrhizus and Lichtheimia corymbifera, two Mucorales species that cause wound mucormycosis worldwide. These models recapitulate the characteristics of combat-related wounds from explosions, including blast overpressure exposure, full-thickness skin injury, fascial damage, and muscle crush. The independent inoculation of both pathogens caused sustained infections and enlarged wounds. Histopathological analysis confirmed the presence of necrosis and fungal hyphae in the wound bed and adjacent muscle tissue. Semi-quantification of fungal burden by colony-forming units corroborated the infection. Treatment with liposomal amphotericin B, 30 mg/kg, effectively controlled R. arrhizus growth and significantly reduced residual fungal burden in infected wounds (p < 0.001). This study establishes the first combat-relevant murine model of wound mucormycosis, paving the way for developing and evaluating novel antifungal therapies against combat-associated WIFDs.
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Affiliation(s)
- Rex J. R. Samdavid Thanapaul
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- NRC Research Associateship Programs, National Academies of Sciences, Engineering, and Medicine, Washington, DC 20001, USA
| | - Yonas A. Alamneh
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Daniel K. Finnegan
- Veterinary Services Program, Pathology Department, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Vlado Antonic
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Rania Abu-Taleb
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Christine Czintos
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Dylan Boone
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Wanwen Su
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Venkatasivasai S. Sajja
- Blast Induced Neurotrauma Branch, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Derese Getnet
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Ashleigh Roberds
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Thomas J. Walsh
- Departments of Medicine and Microbiology & Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, VA 23220, USA
| | - Alexander G. Bobrov
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Bewersdorf TN, Hofmann J, Findeisen S, Schamberger C, Lingner T, Sommer U, Schmidmaier G, Grossner T. Impact of Anti-Mycotic Drugs on the Osteogenic Response of Bone Marrow Mesenchymal Stem Cells In Vitro. Antibiotics (Basel) 2024; 13:186. [PMID: 38391572 PMCID: PMC10886247 DOI: 10.3390/antibiotics13020186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The treatment of fungal bone infections and infected non-unions is a huge challenge in modern trauma and orthopedics, which normally contain the local and systemic administration of anti-fungal drugs. Although frequently used, little is known about the impact of systemic and locally administered fungicides on the osteogenic regenerative capabilities of infected bone tissue, especially upon the osteogenesis of human bone marrow mesenchymal stem cells (BM-hMSCs). This study evaluates the effects of the three most common fungicides for the systemic treatment of bone infections, Voriconazole (VOR), liposomal Amphotericin B (LAMB), and Fluconazole (FLU), as well as the effects of VOR and LAMB-loaded Polymethylmethacrylate (PMMA) cement chips in different concentrations upon the osteogenic response of BM-hMSCs in vitro. Within this study, we compared the ability of BM-hMSC to differentiate into osteoblast-like cells and synthesize hydroxyapatite as assessed by radioactive 99mTechnetium-Hydroxydiphosphonate (99mTc-HDP) labeling, cell proliferation, and analyses of supernatants upon various osteogenic parameters. Our results revealed that VOR added to the cell culture medium affects the osteogenic potential of BM-hMSC negatively, while there were no detectable effects of LAMB and FLU. Moreover, we showed dose-dependent negative effects of high- and extended-dose fungicide-loaded PMMA cement due to cytotoxicity, with a higher cytotoxic potential of VOR than LAMB, while low-dose fungicide-loaded PMMA had no significant effect on the osteogenic potential of BM-hMSC in vitro.
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Affiliation(s)
- Tim Niklas Bewersdorf
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Jakob Hofmann
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Sebastian Findeisen
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Christian Schamberger
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Thomas Lingner
- Genevention GmbH, Rudolf-Wissell-Str. 28A, 37079 Göttingen, Germany
| | - Ulrike Sommer
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Gerhard Schmidmaier
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Tobias Grossner
- Clinic for Trauma and Reconstructive Surgery, Center for Orthopedics, Trauma Surgery and Paraplegiology, University Hospital Heidelberg, 69120 Heidelberg, Germany
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Staruch R, Naumann DN, Wordsworth M, Jeffery S, Rickard R. Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability. BMJ Mil Health 2023:e002227. [PMID: 38053264 DOI: 10.1136/military-2022-002227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/14/2023] [Indexed: 12/07/2023]
Abstract
Understanding tissue loss following injury is important due to its prevalence among the war-wounded and the impact it has on subsequent treatment and rehabilitation. Progressive tissue loss is a type of tissue loss that has complicated extremity injury in recent conflicts. It has resulted in more proximal residual limb lengths and has influenced rehabilitation. Quantifying wound burden in combat casualties remains a challenge due to poor quality of data sets that lack the capacity for detailed analysis. The aims of this article are to outline the current hurdles in attempting to quantify wound burden in combat casualties and to propose simple interventions to improve data capture for future analysis.
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Affiliation(s)
- Robert Staruch
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Department of Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M Wordsworth
- Department of Burns and Plastic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - S Jeffery
- Department of Health Sciences, Aston University, Birmingham, UK
| | - R Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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Herbst I, Helleberg M, Overgaard-Steensen C, Holmgaard R. Mucorales-disseminated infection in burn wound. BMJ Case Rep 2023; 16:e253879. [PMID: 37914163 PMCID: PMC10626915 DOI: 10.1136/bcr-2022-253879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023] Open
Abstract
A previously fit and well man in his 50s was rescued from a burning apartment with Glasgow Coma Scale 3 and admitted to the burn intensive care unit with 18% mixed dermal and full thickness burns and inhalation injury. He received standardised acute burn treatment according to the Emergency Management of Severe Burn guidelines and was found to have acute kidney injury requiring dialysis and cerebral watershed infarcts. The burns were deep especially on the left leg that was deemed unsalvageable and on day 8, he underwent a mid-femoral amputation.A wound swab on day 8 grew mould and with progression of skin necrosis, Mucorales infection was clinically suspected. Microbiological assessment of the swab confirmed Mucorales infection-an invasive fungus with the ability to invade blood vessels leading to vessel thrombosis and tissue necrosis and associated with high mortality. Recommended radical debridement with free cutaneous margins was not possible due to the widespread disease, and the patient was treated conservatively with antifungal therapy and survived.
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Affiliation(s)
- Isabella Herbst
- Department of Plastic Surgery and Burns Treatment, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Rikke Holmgaard
- Department of Plastic Surgery and Burns Treatment, University of Copenhagen, Copenhagen, Denmark
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Holm E, Cook J, Porter K, Nelson A, Weishar R, Mallory T, Cantor A, Croft C, Liwag J, Harrington CJ, DesRosiers TT. A Quantitative and Qualitative Literature Analysis of the Orthopedic Surgeons' Experience: Reflecting on 20 Years in the Global War on Terror. Mil Med 2023; 188:2924-2931. [PMID: 35862000 DOI: 10.1093/milmed/usac219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/18/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION After over 20 years of war in the Middle East, orthopedic injuries have been among the most prevalent combat-related injuries, accounting for 14% of all surgical procedures at Role 2/3 (R2/R3) facilities according to the DoD Trauma Registry. To further delineate the role of the deployed orthopedic surgeon on the modern battlefield, a retrospective review was performed highlighting both quantitative and qualitative analysis factors associated with orthopedic surgical care during the war in the Middle East. METHODS A retrospective review was conducted of orthopedic surgeons in the Middle East from 2001 to 2021. A comprehensive literature search was conducted using the PubMed and Embase databases using a two-reviewer strategy. Articles were compiled and reviewed using Covidence. Inclusion criteria included journal articles focusing on orthopedic injuries sustained during the Global War on Terror (GWoT) in an adult U.S. Military population. In the event of a conflict, a third author would determine the relevance of the article. For the remaining articles, a full-text review was conducted to extract relevant predetermined quantitative data, and the Delphi consensus method was then utilized to highlight relevant qualitative themes. RESULTS The initial search yielded 1,226 potentially relevant articles. In all, 40 studies ultimately met the eligibility criteria. With the consultation of previously deployed orthopedic surgeons at the Walter Reed National Military Medical Center, a retrospective thematic analysis of the 40 studies revealed five themes encompassing the orthopedic surgeons experience throughout GWoT. These themes include unique mechanisms of orthopedic injury compared to previous war injuries due to novel weaponry, differences in interventions depending on R2 versus R3 locations, differences in injuries from those seen in civilian settings, the maintained emphasis on humanitarian aspect of an orthopedic surgeon's mission, and lastly relation of pre-deployment training to perceived deployed success of the orthopedic surgeons. From this extensive review, we found that explosive mechanisms of injury were greatly increased when compared to previous conflicts and were the etiology for the majority of orthopedic injuries sustained. With the increase of complex explosive injuries in the setting of improved body armor and overall survival, R2/3 facilities showed an increased demand for orthopedic intervention including debridement, amputations, and external fixation. Combat injuries sustained during the GWoT differ in the complications, management, and complexity when compared to civilian trauma. "Humanitarian" cases made up a significant number of operative cases for the deployed orthopedic surgeon. Lastly, heterogeneous training opportunities were available prior to deployment (fellowship, combat extremity surgical courses, and dedicated pre-deployment training), and the most commonly identified useful training was learning additional soft-tissue coverage techniques. CONCLUSION These major themes indicate an emphasis on pre-deployment training and the strategic positioning of orthopedic surgeons to reflect the changing landscape of musculoskeletal trauma care. Moving forward, these authors recommend analyzing the comfort and perceived capability of orthopedic surgeons in these unique military environments to best prepare for a changing operational format and the possibility of future peer-peer conflicts that will likely lead to a lack of medical evacuation and prolonged field care.
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Affiliation(s)
- Erik Holm
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - John Cook
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kaitlin Porter
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew Nelson
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert Weishar
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Taylor Mallory
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Addison Cantor
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Caitlynn Croft
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Jonah Liwag
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Colin J Harrington
- Department of Orthopedics, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Taylor T DesRosiers
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Combat Trauma Research Group U.S. Navy, USA
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Tribble DR, Spott MA, Shackleford SA, Gurney JM, Murray BCK. Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice. Mil Med 2022; 187:7-16. [PMID: 35512379 DOI: 10.1093/milmed/usac050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. METHODS The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. RESULTS To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses. CONCLUSIONS To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Mary Ann Spott
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234, USA
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Rodriguez RCJ, Ganesan A, Shaikh F, Carson ML, Bradley W, Warkentien TE, Tribble DR. Combat-Related Invasive Fungal Wound Infections. Mil Med 2022; 187:34-41. [PMID: 35512377 DOI: 10.1093/milmed/usab074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022] Open
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 IFI outbreak investigation (37 IFI patients) and subsequent TIDOS analyses (77 IFI patients) supported development and refinement of a JTS clinical practice guideline for the management of IFIs in war wounds. Furthermore, a local clinical practice guideline to screen for early tissue-based evidence of IFIs among blast casualties at the Landstuhl Regional Medical Center was critically evaluated through a TIDOS investigation, providing additional clinical practice support. Through a collaboration with the Uniformed Services University Surgical Critical Care Initiative, findings from TIDOS analyses were used to support development of a clinical decision support tool to facilitate early risk stratification. CONCLUSIONS Combat-related IFIs are a highly morbid complication following severe blast trauma and remain a threat for future modern warfare. Our findings have supported JTS clinical recommendations, refined IFI classification, and confirmed the utility of PCR-based assays as a complement to histopathology and/or culture to promote early diagnosis. Analyses underway or planned will add to the knowledge base of IFI epidemiology, diagnostics, prevention, and management.
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Affiliation(s)
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA.,Walter Reed National Military Medical Center, Bethesda, MD 20852, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | | | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Global Cutaneous Mucormycosis: A Systematic Review. J Fungi (Basel) 2022; 8:jof8020194. [PMID: 35205948 PMCID: PMC8878367 DOI: 10.3390/jof8020194] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/10/2022] [Accepted: 02/15/2022] [Indexed: 01/27/2023] Open
Abstract
Cutaneous mucormycosis is the third most common clinical type of mucormycosis. The signs and symptoms vary widely, and it is important to make the diagnosis as early as possible in order to achieve a better outcome. We present a systematic review of its epidemiology, clinical presentation, diagnosis, and treatment, analyzing cases published from 1958 until 2021. The review was conducted according to the PRISMA guidelines and included 693 cases from 485 articles from 46 countries. Most publications were from North America (256 cases, 36.9%) and Asia (216 cases, 31.2%). The most common risk factors were diabetes mellitus (20%) and hematological malignancies (15.7%). However, a large proportion of published cases (275, 39.6%) had no identified underlying disease. The most common mode of transmission was trauma (54%), and 108 (15.6%) cases were healthcare-associated. In this review, 291 (42.5%) patients had localized infection, and 90 (13%) had disseminated mucormycosis. In Europe, N. America and S. America, the most common genus was Rhizopus spp., while in Asia it was Apophysomyces spp. (34.7%). Treatment was performed with antifungals, mainly amphotericin B, and/or surgery. Mortality was significantly lower when both antifungals and surgery were applied (29.6%).
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Pottecher J, Lefort H, Adam P, Barbier O, Bouzat P, Charbit J, Galinski M, Garrigue D, Gauss T, Georg Y, Hamada S, Harrois A, Kedzierewicz R, Pasquier P, Prunet B, Roger C, Tazarourte K, Travers S, Velly L, Gil-Jardiné C, Quintard H. Guidelines for the acute care of severe limb trauma patients. Anaesth Crit Care Pain Med 2021; 40:100862. [PMID: 34059492 DOI: 10.1016/j.accpm.2021.100862] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOAL To provide healthcare professionals with comprehensive multidisciplinary expert recommendations for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. DESIGN A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. METHODS The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient's prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS The experts' synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/-) and 12 had a low level of evidence (GRADE 2+/-). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
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Affiliation(s)
- Julien Pottecher
- Service d'Anesthésie-Réanimation & Médecine Péri-Opératoire, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67098 Strasbourg Cedex, France; Université de Strasbourg, FMTS, France.
| | - Hugues Lefort
- Structure des urgences, Hôpital d'Instruction des Armées Legouest, BP 9000, 57077 Metz Cédex 03, France
| | - Philippe Adam
- Service de Chirurgie Orthopédique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, 1 Avenue Molière, 67098 Strasbourg Cedex, France
| | - Olivier Barbier
- Service de Chirurgie Orthopédique et Traumatologie, Hôpital d'Instruction des Armées Sainte Anne, 2 boulevard Sainte Anne, 83000 Toulon, France; Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Bouzat
- Université Grenoble Alpes, Pôle Anesthésie-Réanimation, Centre Hospitalo-Universitaire Grenoble-Alpes, Grenoble, France
| | - Jonathan Charbit
- Soins critiques DAR Lapeyronie, CHU Montpellier, France; Réseau OcciTRAUMA, Réseau Régional Occitanie de prise en charge des traumatisés sévères, France
| | - Michel Galinski
- Pôle urgences adultes - SAMU 33, Hôpital Pellegrin, CHU de Bordeaux 3300 Bordeaux, France; INSERM U1219, ISPED, Bordeaux Population Health Research Center INSERM U1219-"Injury Epidemiology Transport Occupation" Team, F-33076 Bordeaux Cedex, France
| | - Delphine Garrigue
- Pôle d'Anesthésie Réanimation, Pôle de l'Urgence, CHU Lille, F-59000 Lille, France
| | - Tobias Gauss
- Service d'Anesthésie-Réanimation, Hôpital Beaujon, DMU PARABOL, AP-HP Nord, Clichy, France; Université de Paris, Paris, France
| | - Yannick Georg
- Service de Chirurgie Vasculaire et Transplantation Rénale, Hôpitaux Universitaire de Strasbourg, Strasbourg, France
| | - Sophie Hamada
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France
| | - Anatole Harrois
- Département d'anesthésie-réanimation, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, France
| | - Romain Kedzierewicz
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Bureau de Médecine d'Urgence, Division Santé, Brigade de Sapeurs-Pompiers de Paris, 1 place Jules Renard, 75017 Paris, France
| | - Pierre Pasquier
- Département anesthésie-réanimation, Hôpital d'instruction des armées Percy, Clamart, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Bertrand Prunet
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - Claire Roger
- Service de Réanimation Chirurgicale, Pôle Anesthésie Réanimation Douleur Urgence, CHU Carémeau, 30000 Nîmes, France
| | - Karim Tazarourte
- Service SAMU-Urgences, CHU Edouard Herriot, Hospices civils de Lyon, Lyon, France; Université Lyon 1 Hesper EA 7425, Lyon, France
| | - Stéphane Travers
- Ecole du Val de Grace, 2 place Alphonse Laveran, 75005 Paris, France; 1ère Chefferie du Service de Santé, Villacoublay, France
| | - Lionel Velly
- Service d'Anesthésie Réanimation, CHU Timone Adultes, 264 rue St Pierre 13005 Marseille, France; MeCA, Institut de Neurosciences de la Timone - UMR 7289, Aix Marseille Université, Marseille, France
| | - Cédric Gil-Jardiné
- Pôle Urgences adultes SAMU-SMUR, CHU Bordeaux, Bordeaux Population Health - INSERM U1219 Université de Bordeaux, Equipe IETO, Bordeaux, France
| | - Hervé Quintard
- Soins Intensifs, Hôpitaux Universitaires de Genève, Genève, Suisse
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12
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Designed Antimicrobial Peptides Against Trauma-Related Cutaneous Invasive Fungal Wound Infections. J Fungi (Basel) 2020; 6:jof6030184. [PMID: 32971819 PMCID: PMC7559897 DOI: 10.3390/jof6030184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/22/2023] Open
Abstract
Cutaneous invasive fungal wound infections after life-threatening dismounted complex blast injury (DCBI) and natural disasters complicate clinical care. These wounds often require aggressive repeated surgical debridement, can result in amputations and hemipelvectomies and have a 38% mortality rate. Given the substantial morbidity associated with cutaneous fungal wound infections, patients at risk need immediate empiric treatment mandating the use of rapidly acting broad-spectrum antimicrobials, acting on both fungi and bacteria, that are also effective against biofilm and can be administered topically. Designed antimicrobial peptides (dAMPs) are engineered analogues of innate antimicrobial peptides which provide the first line of defense against invading pathogens. The antifungal and antibacterial effect and mammalian cytotoxicity of seven innovative dAMPs, created by iterative structural analog revisions and physicochemical and functional testing were investigated. The dAMPs possess broad-spectrum antifungal activity, in addition to being effective against Gram-negative and Gram-positive bacteria, which is crucial as many wounds are polymicrobial and require immediate empiric treatment. Three of the most potent dAMPs—RP504, RP556 and RP557—possess limited mammalian cytotoxicity following 8 h incubation. If these encouraging broad-spectrum antimicrobial and rapid acting results are translated clinically, these novel dAMPs may become a first line empiric topical treatment for traumatic wound injuries.
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Tribble DR, Ganesan A, Rodriguez CJ. Combat trauma-related invasive fungal wound infections. CURRENT FUNGAL INFECTION REPORTS 2020; 14:186-196. [PMID: 32665807 DOI: 10.1007/s12281-020-00385-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose of review This review highlights research from the past five years on combat trauma-related invasive fungal wound infections (IFIs) with a focus on risk stratification to aid patient management, microbiology, and diagnostics. Recent Findings A revised classification scheme stratifies wounds into three risk groups: IFI, High Suspicion of IFI, and Low Suspicion of IFI. This stratification is based on persistence of wound necrosis and laboratory fungal evidence, presence of signs/symptoms of deep soft-tissue infections, and the need for antifungals. Use of this classification could allow for prioritization of antifungal therapy. Further, IFIs delay wound healing, particularly when caused by fungi of the order Mucorales. Lastly, molecular sequencing offers promising and complimentary results to the gold standard histopathology. Summary Optimal management of combat-related IFIs depends on early tissue-based diagnosis with aggressive surgical debridement and concomitant dual antifungal therapy. Further research on clinical decision support tools and rapid diagnostics are needed.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda MD 20817.,Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
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Ganesan A, Shaikh F, Bradley W, Blyth DM, Bennett D, Petfield JL, Carson ML, Wells JM, Tribble DR. Classification of Trauma-Associated Invasive Fungal Infections to Support Wound Treatment Decisions. Emerg Infect Dis 2020; 25. [PMID: 31441428 PMCID: PMC6711217 DOI: 10.3201/eid2509.190168] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The proposed classification, based on diagnostic certainty, provides a framework for determining initial empiric and subsequent targeted therapy. To evaluate a classification system to support clinical decisions for treatment of contaminated deep wounds at risk for an invasive fungal infection (IFI), we studied 246 US service members (413 wounds) injured in Afghanistan (2009–2014) who had laboratory evidence of fungal infection. A total of 143 wounds with persistent necrosis and laboratory evidence were classified as IFI; 120 wounds not meeting IFI criteria were classified as high suspicion (patients had localized infection signs/symptoms and had received antifungal medication for >10 days), and 150 were classified as low suspicion (failed to meet these criteria). IFI patients received more blood than other patients and had more severe injuries than patients in the low-suspicion group. Fungi of the order Mucorales were more frequently isolated from IFI (39%) and high-suspicion (21%) wounds than from low-suspicion (9%) wounds. Wounds that did not require immediate antifungal therapy lacked necrosis and localized signs/symptoms of infection and contained fungi from orders other than Mucorales.
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15
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Ganesan A, Wells J, Shaikh F, Peterson P, Bradley W, Carson ML, Petfield JL, Klassen-Fischer M, Akers KS, Downing K, Bialek R, Tribble DR, Wickes BL. Molecular Detection of Filamentous Fungi in Formalin-Fixed Paraffin-Embedded Specimens in Invasive Fungal Wound Infections Is Feasible with High Specificity. J Clin Microbiol 2019; 58:e01259-19. [PMID: 31619528 PMCID: PMC6935896 DOI: 10.1128/jcm.01259-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/10/2019] [Indexed: 12/14/2022] Open
Abstract
Trauma-related invasive fungal wound infections (IFIs) are associated with significant morbidity and mortality. Early identification and treatment are critical. Traditional identification methods (e.g., fungal cultures and histopathology) can be delayed and insensitive. We assessed a PCR-based sequencing assay for rapid identification of filamentous fungi in formalin-fixed paraffin-embedded (FFPE) specimens obtained from combat casualties injured in Afghanistan. Blinded FFPE specimens from cases (specimens positive on histopathology) and controls (specimens negative on histopathology) were submitted for evaluation with a panfungal PCR. The internal transcribed spacer 2 (ITS2) region of the fungal ribosomal repeat was amplified and sequenced. The PCR results were compared with findings from histopathology and/or culture. If injury sites contributed multiple specimens, findings for the site were collapsed to the site level. We included 64 case subjects (contributing 95 sites) and 102 controls (contributing 118 sites). Compared to histopathology, panfungal PCR was specific (99%), but not as sensitive (63%); however, sensitivity improved to 83% in specimens from sites with angioinvasion. Panfungal PCR identified fungi of the order Mucorales in 33 of 44 sites with angioinvasion (75%), whereas fungal culture was positive in 20 of 44 sites (45%). Saksenaea spp. were the dominant fungi identified by PCR in specimens from angioinvasion sites (57%). Panfungal PCR is specific, albeit with lower sensitivity, and performs better at identifying fungi of the order Mucorales than culture. DNA sequencing offers significant promise for the rapid identification of fungal infection in trauma-related injuries, leading to more timely and accurate diagnoses.
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Affiliation(s)
- Anuradha Ganesan
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Justin Wells
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Philip Peterson
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | | | | | - Kevin S Akers
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | - Kevin Downing
- Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Ralf Bialek
- LADR GmbH Medizinisches Versorgungszentrum Dr. Kramer und Kollegen, Geesthacht, Germany
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Brian L Wickes
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA
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McGraw C, Carrick M, Ekengren F, Berg G, Lieser M, Orlando A, Madayag R, Tanner Ii A, Kelly M, Banton K, Bar-Or D. Severe fungal infections following blunt traumatic injuries: A 5-year multicenter descriptive study. Injury 2019; 50:2234-2239. [PMID: 31630781 DOI: 10.1016/j.injury.2019.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/12/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aggressive and timely treatment of post-traumatic fungal infections is the most efficacious way to reduce morbidity and mortality. Compared to the military trauma population, studies reporting on fungal infections in civilian trauma are not well described. The purpose of this study was to describe characteristics of civilian trauma patients who developed fungal infections and to identify common risk factors and report any delays between injury and treatment. METHODS This was a five-year (1/1/2013-3/1/2018) retrospective, descriptive study across six level 1 trauma centers. All consecutively admitted trauma patients (≥18 years) with laboratory-confirmed fungal wound infections were included. Patients with solely candida wound isolates were excluded. Patient demographics, clinical wound and infection characteristics, organisms cultured, treatment modalities, length of stay, in-hospital mortality, and any diagnostic or treatment delays were described. RESULTS Of the 54,521 trauma patients screened for fungal infection, 12 were identified. All patients suffered major injuries after blunt trauma (abbreviated injury score 3-5) and sustained wound contamination, and in nine patients, the cause of injury was motor vehicle. Six had open wounds/fractures on admission. The geographical region with the highest rate of fungal infection was Texas (n = 7), followed by Kansas (N = 3), then Missouri (N = 2). First symptoms of infection (leukocytosis or fever (n = 10)) presented a median of 6.3 (4.1-9.8) days after injury. Wound management entailed a combination of debridements (n = 8), negative pressure wound therapy (n = 9), amputation (n = 6), and antifungal treatment (n = 10). All fungal isolates identified from the wound site were hyphomycetes. A median of 2.1 (1.8-4.0) days passed from diagnosis to first antifungal treatment, and 3 patients died. CONCLUSIONS Our study shows the challenges surrounding diagnosis and treatment of fungal infections secondary to trauma. Non-specific fungal infection symptoms, such as leukocytosis and fever, typically presented a week after injury. Vigilance for investigating risk factors and infection symptoms may help clinicians with more timely management of trauma patients with a severe fungal infection.
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Affiliation(s)
- Constance McGraw
- Medical City Plano, Trauma Research Department, Plano, TX, United States; Wesley Medical Center, Trauma Research Department, Wichita, KS, United States; Research Medical Center, Trauma Research Department, Kansas City, MO, United States; St. Anthony Hospital, Trauma Research Department, Lakewood, CO, United States; Penrose Hospital, Trauma Research Department, Colorado Springs, CO, United States; Swedish Medical Center, Trauma Research Department, Englewood, CO, United States
| | - Matthew Carrick
- Medical City Plano, Trauma Services Department, Plano, TX, United States
| | - Francie Ekengren
- Wesley Medical Center, Trauma Services Department, Wichita, KS, United States
| | - Gina Berg
- Wesley Medical Center, Trauma Services Department, Wichita, KS, United States
| | - Mark Lieser
- Research Medical Center, Trauma Services Department, Kansas City, MO, United States
| | - Alessandro Orlando
- Medical City Plano, Trauma Research Department, Plano, TX, United States; Wesley Medical Center, Trauma Research Department, Wichita, KS, United States; Research Medical Center, Trauma Research Department, Kansas City, MO, United States; St. Anthony Hospital, Trauma Research Department, Lakewood, CO, United States; Penrose Hospital, Trauma Research Department, Colorado Springs, CO, United States; Swedish Medical Center, Trauma Research Department, Englewood, CO, United States
| | - Robert Madayag
- St. Anthony Hospital, Trauma Services Department, Lakewood, CO, United States
| | - Allen Tanner Ii
- Penrose Hospital, Trauma Services Department, Colorado Springs, CO, United States
| | - Michael Kelly
- Penrose Hospital, Trauma Services Department, Colorado Springs, CO, United States
| | - Kaysie Banton
- Swedish Medical Center, Trauma Services Department, Englewood, CO, United States
| | - David Bar-Or
- Medical City Plano, Trauma Research Department, Plano, TX, United States; Wesley Medical Center, Trauma Research Department, Wichita, KS, United States; Research Medical Center, Trauma Research Department, Kansas City, MO, United States; St. Anthony Hospital, Trauma Research Department, Lakewood, CO, United States; Penrose Hospital, Trauma Research Department, Colorado Springs, CO, United States; Swedish Medical Center, Trauma Research Department, Englewood, CO, United States.
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17
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Tribble DR, Murray CK, Lloyd BA, Ganesan A, Mende K, Blyth DM, Petfield JL, McDonald J. After the Battlefield: Infectious Complications among Wounded Warriors in the Trauma Infectious Disease Outcomes Study. Mil Med 2019; 184:18-25. [PMID: 31778199 PMCID: PMC6886670 DOI: 10.1093/milmed/usz027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/04/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION During recent wars in Iraq and Afghanistan, improved survivability in severe trauma corresponded with a rise in the proportion of trauma-related infections, including those associated with multidrug-resistant organisms (MDROs). Significant morbidity was reported in association with the infections. There is also concern regarding potential long-term impacts of the trauma-related infectious complications. Therefore, to meet the critical need of prospective collection of standardized infection-related data to understand the disease burden and improve outcomes of wounded personnel, the Trauma Infectious Disease Outcomes Study (TIDOS) was developed. Herein, we review accomplishments and key peer-reviewed findings of TIDOS. METHODS The TIDOS project is a multicenter observational study of short- and long-term infectious complications following deployment-related trauma. Wounded military personnel medevac'd to Landstuhl Regional Medical Center (LRMC; Germany) before transfer to a participating US military hospital between June 2009 and December 2014 were eligible for inclusion. An infectious disease module to supplement the Department of Defense Trauma Registry by collecting infection-related data from all trauma patients admitted to participating hospitals was developed. Specimens from trauma patients were also collected and retained in a microbiological isolate repository. During the initial hospitalization, patients were given the opportunity to enroll in a prospective follow-up cohort study. Patients who received Department of Veterans Affairs (VA) care were also given the opportunity to consent to ongoing VA follow-up. RESULTS A total of 2,699 patients transferred to participating military hospitals in the USA, of which 1,359 (50%) patients enrolled in the TIDOS follow-up cohort. In addition, 638 enrolled in the TIDOS-VA cohort (52% of TIDOS enrollees who entered VA healthcare). More than 8,000 isolates were collected from infection control surveillance and diagnostic evaluations and retained in the TIDOS Microbiological Repository. Approximately 34% of the 2,699 patients at US hospitals developed a trauma-related infection during their initial hospitalization with skin and soft-tissue infections being predominant. After discharge from the US hospitals, approximately one-third of TIDOS cohort enrollees developed a new trauma-related infection during follow-up and extremity wound infections (skin and soft-tissue infections and osteomyelitis) continued to be the majority. Among TIDOS cohort enrollees who received VA healthcare, 38% developed a new trauma-related infection with the incident infection being diagnosed a median of 88 days (interquartile range: 19-351 days) following hospital discharge. Data from TIDOS have been used to support the development of Joint Trauma System clinical practice guidelines for the prevention of combat-related infections, as well as the management of invasive fungal wound infections. Lastly, due to the increasing proportion of infections associated with MDROs, TIDOS investigators have collaborated with investigators across military laboratories as part of the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative with the objective of improving the understanding of the complex wound microbiology in order to develop novel infectious disease countermeasures. CONCLUSIONS The TIDOS project has focused research on four initiatives: (1) blast-related wound infection epidemiology and clinical management; (2) DoD-VA outcomes research; (3) Multidrug- Resistant and other Virulent Organisms Trauma Infections Initiative; and (4) Joint Trauma System clinical practice guidelines and antibiotic stewardship. There is a continuing need for longitudinal data platforms to support battlefield wound research and clinical practice guideline recommendation refinement, particularly to improve care for future conflicts. As such, maintaining a research platform, such as TIDOS, would negate the lengthy time needed to initiate data collection and analysis.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
- Current affiliation is 1st Area Medical Laboratory, Aberdeen Proving Ground, MD
| | - Bradley A Lloyd
- Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 09180
- Current affiliation is Wright Patterson Medical Center, OH
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20852
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720 A Rockledge Drive, Bethesda, MD 20817
| | - Katrin Mende
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720 A Rockledge Drive, Bethesda, MD 20817
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Joseph L Petfield
- Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 09180
| | - Jay McDonald
- Veterans Affairs St. Louis Health Care System, 915 N Grand Blvd, St. Louis, MO 63106
- Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO 63110
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Potter BK, Forsberg JA, Silvius E, Wagner M, Khatri V, Schobel SA, Belard AJ, Weintrob AC, Tribble DR, Elster EA. Combat-Related Invasive Fungal Infections: Development of a Clinically Applicable Clinical Decision Support System for Early Risk Stratification. Mil Med 2019; 184:e235-e242. [PMID: 30124943 DOI: 10.1093/milmed/usy182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Benjamin K Potter
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Jonathan A Forsberg
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD.,Regenerative Medicine Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD
| | - Elizabeth Silvius
- Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD.,DecisionQ Corporation, 2500 Wilson Blvd #325, Arlington, VA
| | - Matthew Wagner
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Vivek Khatri
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Seth A Schobel
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Arnaud J Belard
- Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive #100, Bethesda, MD.,Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC
| | - David R Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD
| | - Eric A Elster
- Department of Surgery, Uniformed Services University of the Health Sciences & Walter Reed National Military Medical Center, 4301 Jones Bridge Road, Bethesda, MD.,Surgical Critical Care Initiative (SC2i), 4301 Jones Bridge Road, Bethesda, MD
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19
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Walsh TJ, Hospenthal DR, Petraitis V, Kontoyiannis DP. Necrotizing Mucormycosis of Wounds Following Combat Injuries, Natural Disasters, Burns, and Other Trauma. J Fungi (Basel) 2019; 5:jof5030057. [PMID: 31277364 PMCID: PMC6787580 DOI: 10.3390/jof5030057] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 01/30/2023] Open
Abstract
Necrotizing mucormycosis is a devastating complication of wounds incurred in the setting of military (combat) injuries, natural disasters, burns, or other civilian trauma. Apophysomyces species, Saksenaea species and Lichtheimia (formerly Absidia) species, although uncommon as causes of sinopulmonary mucormycosis, are relatively frequent agents of trauma-related mucormycosis. The pathogenesis of these infections likely involves a complex interaction among organism, impaired innate host defenses, and biofilms related to traumatically implanted foreign materials. Effective management depends upon timely diagnosis, thorough surgical debridement, and early initiation of antifungal therapy.
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Affiliation(s)
- Thomas J Walsh
- Departments of Medicine, Pediatrics, and Microbiology & Immunology; Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital, New York, NY 10065, USA.
| | - Duane R Hospenthal
- Division of Infectious Diseases, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Vidmantas Petraitis
- Departments of Medicine, Weill Cornell Medicine of Cornell University, New York, NY 10065, USA
| | - Dimitrios P Kontoyiannis
- Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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20
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Liang SY, Jackson B, Kuhn J, Shaikh F, Blyth DM, Whitman TJ, Petfield JL, Carson ML, Tribble DR, McDonald JR. Urinary Tract Infections after Combat-Related Genitourinary Trauma. Surg Infect (Larchmt) 2019; 20:611-618. [PMID: 31112074 DOI: 10.1089/sur.2019.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: We examined clinical outcomes among combat casualties with genitourinary injuries after blast trauma. Methods: Characteristics, clinical care, urologic complications, and infections for subjects enrolled in the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) sources. Logistic regression identified predictors for urinary tract infections (UTIs) after genitourinary trauma. Results: Among 530 TIDOS enrollees who entered VA care, 89 (17%) sustained genitourinary trauma. The majority of subjects (93%) were injured via a blast and 27% had a dismounted complex blast injury (DCBI). Sexual dysfunction was reported with 36% of subjects, whereas 14% had urinary retention/incontinence and 8% had urethral stricture. Urologic complications were comparable between patients with and without DCBIs. Nineteen (21%) subjects had one or more UTI with a total of 40 unique UTI events (25% during initial hospitalization and 75% during subsequent DOD or VA care). The UTI incidence rate was 0.89 per patient-year during initial hospitalization, 0.05 per patient-year during DOD follow-up, and 0.07 per patient-year during VA healthcare. Subjects with UTIs had a higher proportion of bladder injury (53% vs. 13%; p < 0.001), posterior urethral injury (26% vs. 1%; p = 0.001), pelvic fracture (47% vs. 4%; p < 0.001), soft-tissue infection of the pelvis/hip (37% vs. 4%; p = 0.001), urinary catheterization (47% vs. 11%; p < 0.001), urinary retention or incontinence (42% vs. 6%; p < 0.001), and stricture (26% vs. 3%; p = 0.004) compared with patients with genitourinary trauma and no UTI. Independent UTI risk factors were occurrence of a soft-tissue infection at the pelvis/hip, trauma to the urinary tract, and transtibial amputation. Conclusions: Among combat casualties with genitourinary trauma, UTIs are a common complication, particularly with severe blast injury and urologic sequelae. Episodes of UTIs typically occur early after the initial injury while in DOD care, however, recurrent infections may continue into long-term VA care.
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Affiliation(s)
- Stephen Y Liang
- Washington University School of Medicine, St. Louis, Missouri
| | - Brendan Jackson
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Janis Kuhn
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | | | | | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jay R McDonald
- Washington University School of Medicine, St. Louis, Missouri.,Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
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21
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Rodriguez CJ, Tribble DR, Malone DL, Murray CK, Jessie EM, Khan M, Fleming ME, Potter BK, Gordon WT, Shackelford SA. Treatment of Suspected Invasive Fungal Infection in War Wounds. Mil Med 2019; 183:142-146. [PMID: 30189071 DOI: 10.1093/milmed/usy079] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Indexed: 11/14/2022] Open
Abstract
Invasive fungal wound infections (IFIs) were an unexpected complication associated with blast-related wounds during Operation Enduring Freedom. Between 2010 and 2012, IFI incidence rates were as high as 10-12% for patients injured during Operation Enduring Freedom and admitted to the intensive care unit at the Landstuhl Regional Medical Center. Independent risk factors for the development of IFIs include dismounted blast injuries, above knee amputations and massive (>20 units) packed red blood cell transfusions within 24 hours after injury. The Joint Trauma System developed a Clinical Practice Guideline on IFI prevention, identification and management. Aggressive and frequent surgical debridement remains the primary therapy accompanied by topical antifungal therapy (e.g., Dakins solution). Empiric systemic antifungal therapy with both liposomal amphotericin B and an intravenous broad-spectrum triazole (e.g., voriconazole or posaconazole) should be administered when there is strong suspicion of IFI based on the occurrence of recurrent wound necrosis following serial surgical debridements, since many cases involve multiple fungal species. 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.
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Affiliation(s)
- Carlos J Rodriguez
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - David R Tribble
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Debra L Malone
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Clinton K Murray
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Elliot M Jessie
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Mansoor Khan
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Mark E Fleming
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Benjamin K Potter
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Wade T Gordon
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Stacy A Shackelford
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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22
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Mangum LC, Franklin NA, Garcia GR, Akers KS, Wenke JC. Rapid degradation and non-selectivity of Dakin's solution prevents effectiveness in contaminated musculoskeletal wound models. Injury 2018; 49:1763-1773. [PMID: 30104015 DOI: 10.1016/j.injury.2018.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/04/2018] [Accepted: 08/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dakin's solution (buffered sodium hypochlorite) has been used as a topical adjunct for the treatment of invasive fungal infections in trauma patients. Prudent use of Dakin's solution (DS) for complex musculoskeletal wound management implies balancing antimicrobial efficacy and human tissue toxicity, but little empirical evidence exists to inform clinical practice. To identify potentially efficacious DS concentrations and application methods, we conducted two animal studies to evaluate the ability of DS to reduce bacterial burden in small and large animal models of contaminated musculoskeletal wounds. METHODS An established rat (Rattus norvegicus) contaminated femoral defect model was employed to evaluate the antimicrobial efficacy of DS as a topical adjunctive treatment for Staphylococcus aureus infection. A range of clinically-relevant DS concentrations (0.00025%-0.125%) were tested, both with and without periodic replenishment during treatment. Next, an established goat (Capra hircus) musculoskeletal wound model, consisting of a Pseudomonas aeruginosa contaminated proximal tibia cortical defect, muscle crush, and thermal injury, was utilized to evaluate the antimicrobial efficacy of dilute DS (0.0025% and 0.025%) as a surgical irrigant solution. In situ reactive chlorine concentrations were monitored throughout each treatment using an automated iodometric titration approach. RESULTS In a rat wound model, DS treatment did not significantly reduce S. aureus bioburden after 14 days as compared to saline control. Two treatment groups (0.01% single application and 0.025% multiple application) exhibited significantly higher bacterial burden than control. In a goat musculoskeletal wound model, neither 0.0025% nor 0.025% DS significantly altered P. aeruginosa bioburden immediately following treatment or at 48 h post-treatment. Overall, DS applied to exposed soft tissue exhibited rapid degradation, e.g., 0.125% DS degraded 32% after 5 s progressing to 86% degradation after 15 min following single application. CONCLUSIONS We did not observe evidence of a therapeutic benefit following Dakin's solution treatment for any tested concentration or application method in two contaminated musculoskeletal wound models. Despite confirmation of robust bactericidal activity in vitro, our findings suggest DS at current clinically-used concentrations does not kill tissue surface-attached bacteria, nor does it necessarily cause host tissue toxicity that exacerbates infection in the setting of complex musculoskeletal injury.
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Affiliation(s)
- Lee C Mangum
- Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA.
| | - Nathan A Franklin
- Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA; Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Gerardo R Garcia
- Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Kevin S Akers
- Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA; Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Joseph C Wenke
- Extremity Trauma and Regenerative Medicine, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
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23
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24
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Vicente DA, Bradley MJ, Bograd B, Leonhardt C, Elster EA, Davis TA. The impact of septic stimuli on the systemic inflammatory response and physiologic insult in a preclinical non-human primate model of polytraumatic injury. J Inflamm (Lond) 2018; 15:11. [PMID: 29849508 PMCID: PMC5968671 DOI: 10.1186/s12950-018-0187-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Established animal trauma models are limited in recapitulating the pathophysiology of human traumatic injury. Herein, we characterize the physiologic insult and inflammatory response in two clinically relevant non-human primate (NHP) trauma models. METHODS Mauritian Cynomolgus Macaques underwent either a laparoscopic closed abdomen liver injury (laparoscopic 60% left-lobe hepatectomy) in an established uncontrolled severe hemorrhage model (THM), or a polytrauma hemorrhage model (PHM) involving combined liver and bowel injury, uncontrolled severe hemorrhage as well as an open full-thickness cutaneous flank wound. Fixed volume resuscitation strategies were employed in the THM and goal directed resuscitation was used in the PHM. Complete peripheral blood and critical clinical chemistry parameters, serum biomarkers of systemic inflammation, tissue perfusion parameters, as well as survival, were compared between the models throughout the 2-week study period. RESULTS NHPs in both the THM (n = 7) and the PHM (n = 21) demonstrated tissue hypoperfusion (peak lactate 6.3 ± 0.71 mmol/L) with end organ injury (peak creatinine 3.08 ± 0.69 mg/dL) from a similar liver injury (60% left hemi-hepatectomy), though the PHM NHPs had a significantly higher blood loss (68.1% ± 12.7% vs. 34.3% ± 2.3%, p = 0.02), lower platelet counts (59 ± 25 vs. 205 ± 46 K/uL, p = 0.03) and a trend towards higher mortality (90.5% vs. 33.3%, p = 0.09). The inflammatory response was robust in both models with peak cytokine (IL-6 > 6000-fold above baseline) and peak leukocyte values (WBC 27 K/uL) typically occurring around t = 240 min from the time of hepatic injury. A more robust systemic inflammatory response was appreciated in the PHM resulting in marked elevations in peak serum IL-6 (7887 ± 2521 pg/mL vs.1076 ± 4833 pg/mL, p = 0.02), IL-1ra (34,499 ± 5987 pg/mL vs. 2511 ± 1228 pg/mL, p < 0.00), and IL-10 (13,411 pg/mL ± 5598 pg/mL vs. 617 pg/mL ± 252 pg/mL, p = 0.03). CONCLUSION This comparative analysis provides a unique longitudinal perspective on the post-injury inflammatory response in two clinically relevant models, and demonstrates that the addition of septic stimuli to solid organ injury increases both the hemorrhagic insult and inflammatory response.
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Affiliation(s)
- Diego A. Vicente
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD USA
- Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Matthew J. Bradley
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD USA
- Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Benjamin Bograd
- Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Crystal Leonhardt
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD USA
| | - Eric A. Elster
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD USA
- Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Thomas A. Davis
- Department of Regenerative Medicine, Naval Medical Research Center, Silver Spring, MD USA
- Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD USA
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25
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Infectious Complications After Battlefield Injuries: Epidemiology, Prevention, and Treatment. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0102-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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26
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Tribble DR, Li P, Warkentien TE, Lloyd BA, Schnaubelt ER, Ganesan A, Bradley W, Aggarwal D, Carson ML, Weintrob AC, Murray CK. Impact of Operational Theater on Combat and Noncombat Trauma-Related Infections. Mil Med 2017; 181:1258-1268. [PMID: 27753561 DOI: 10.7205/milmed-d-15-00368] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The Trauma Infectious Disease Outcomes Study began in June 2009 as combat operations were decreasing in Iraq and increasing in Afghanistan. Our analysis examines the rate of infections of wounded U.S. military personnel from operational theaters in Iraq and Afghanistan admitted to Landstuhl Regional Medical Center between June 2009 and December 2013 and transferred to a participating U.S. hospital. Infection risk factors were examined in a multivariate logistic regression analysis (expressed as odds ratios [OR]; 95% confidence intervals [CI]). The study population includes 524 wounded military personnel from Iraq and 4,766 from Afghanistan. The proportion of patients with at least one infection was 28% and 34% from the Iraq and Afghanistan theaters, respectively. The incidence density rate was 2.0 (per 100 person-days) for Iraq and 2.7 infections for Afghanistan. Independent risk factors included large-volume blood product transfusions (OR: 10.68; CI: 6.73-16.95), high Injury Severity Score (OR: 2.48; CI: 1.81-3.41), and improvised explosive device injury mechanism (OR: 1.84; CI: 1.35-2.49). Operational theater (OR: 1.32; CI: 0.87-1.99) was not a risk factor. The difference in infection rates between operational theaters is primarily a result of increased injury severity in Afghanistan from a higher proportion of blast-related trauma during the study period.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Tyler E Warkentien
- Infectious Disease, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Bradley A Lloyd
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
| | - Elizabeth R Schnaubelt
- Infectious Disease, Landstuhl Regional Medical Center, CMR 402, Box 1559, APO AE 09180, Landstuhl, Germany
| | - Anuradha Ganesan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
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27
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Kronen R, Liang SY, Bochicchio G, Bochicchio K, Powderly WG, Spec A. Invasive Fungal Infections Secondary to Traumatic Injury. Int J Infect Dis 2017; 62:102-111. [PMID: 28705753 DOI: 10.1016/j.ijid.2017.07.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/30/2017] [Accepted: 07/05/2017] [Indexed: 12/20/2022] Open
Abstract
Invasive fungal infection (IFI) is a rare but serious complication of traumatic injury. The purpose of this article is to review the epidemiology, natural history, mycology, risk factors, diagnosis, treatment, and outcomes associated with post-traumatic IFI in military and civilian populations. The epidemiology of post-traumatic IFI is poorly characterized, but incidence appears to be rising. Patients often suffer from severe injuries and require extensive medical interventions. Fungi belonging to the order Mucorales are responsible for most post-traumatic IFI in both civilian and military populations. Risk factors differ between these cohorts but include specific injury patterns and comorbidities. Diagnosis of post-traumatic IFI typically follows positive laboratory results in the appropriate clinical context. The gold standard of treatment is surgical debridement in addition to systemic antifungal therapy. Patients with post-traumatic IFI may be at greater risk of amputation, delays in wound healing, hospital complications, and death as compared to trauma patients who do not develop IFI. More research is needed to understand the factors surrounding the development and management of post-traumatic IFI to reduce the significant morbidity and mortality associated with this disease.
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Affiliation(s)
- Ryan Kronen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA.
| | - Stephen Y Liang
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA; Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Grant Bochicchio
- Section of Acute and Critical Care Surgery, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Kelly Bochicchio
- Section of Acute and Critical Care Surgery, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - William G Powderly
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO, USA.
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28
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Scientific and Clinical Abstracts From the WOCN® Society's 49th Annual Conference. J Wound Ostomy Continence Nurs 2017. [DOI: 10.1097/won.0000000000000331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Cannon JW, Hofmann LJ, Glasgow SC, Potter BK, Rodriguez CJ, Cancio LC, Rasmussen TE, Fries CA, Davis MR, Jezior JR, Mullins RJ, Elster EA. Dismounted Complex Blast Injuries: A Comprehensive Review of the Modern Combat Experience. J Am Coll Surg 2016; 223:652-664.e8. [PMID: 27481095 DOI: 10.1016/j.jamcollsurg.2016.07.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Jeremy W Cannon
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Luke J Hofmann
- Department of Surgery, William Beaumont Army Medical Center, El Paso, TX; General Surgery, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD
| | - Sean C Glasgow
- Department of Surgery, Washington University, St Louis, MO; USAF Center for the Sustainment of Trauma and Resuscitative Skills (C-STARS), St Louis, MO
| | - Benjamin K Potter
- Orthopaedics, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD
| | - Carlos J Rodriguez
- General Surgery, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD
| | | | - Todd E Rasmussen
- Vascular Surgery, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD; US Combat Casualty Care Research Program, Ft Detrick, MD
| | - C Anton Fries
- US Army Institute of Surgical Research, Ft Sam Houston, TX
| | - Michael R Davis
- General Surgery, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD; US Army Institute of Surgical Research, Ft Sam Houston, TX
| | - James R Jezior
- Urology, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD
| | - Richard J Mullins
- Department of Surgery, Oregon Health and Sciences University, Portland, OR
| | - Eric A Elster
- General Surgery, Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD
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30
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Heaton SM, Weintrob AC, Downing K, Keenan B, Aggarwal D, Shaikh F, Tribble DR, Wells J. Histopathological techniques for the diagnosis of combat-related invasive fungal wound infections. BMC Clin Pathol 2016; 16:11. [PMID: 27398067 PMCID: PMC4937573 DOI: 10.1186/s12907-016-0033-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/20/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective management of trauma-related invasive fungal wound infections (IFIs) depends on early diagnosis and timely initiation of treatment. We evaluated the utility of routine staining, histochemical stains and frozen section for fungal element identification. METHODS A total of 383 histopathological specimens collected from 66 combat-injured United States military personnel with IFIs were independently reviewed by two pathologists. Both periodic acid-Schiff (PAS) and Gomori methenamine silver (GMS) stains were used on 74 specimens. The performance of the two special stains was compared against the finding of fungal elements via any histopathological method (ie, special stains or hematoxylin and eosin). In addition, the findings from frozen sections were compared against permanent sections. RESULTS The GMS and PAS results were 84 % concordant (95 % confidence interval: 70 to 97 %). The false negative rate of fungal detection was 15 % for GMS and 44 % for PAS, suggesting that GMS was more sensitive; however, neither stain was statistically significantly superior for identifying fungal elements (p = 0.38). Moreover, 147 specimens had frozen sections performed, of which there was 87 % correlation with permanent sections (60 % sensitivity and 98 % specificity). In 27 permanent sections, corresponding cultures were available for comparison and 85 % concordance in general species identification was reported. CONCLUSIONS The use of both stains does not have an added benefit for identifying fungal elements. Furthermore, while the high specificity of frozen section may aid in timely IFI diagnoses, it should not be used as a stand-alone method to guide therapy due to its low sensitivity.
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Affiliation(s)
- Sarah M Heaton
- Department of Pathology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814 USA
| | - Amy C Weintrob
- Department of Pathology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814 USA ; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD USA ; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - Kevin Downing
- Department of Pathology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814 USA
| | - Bryan Keenan
- Department of Pathology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814 USA
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD USA ; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD USA ; The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD USA
| | - Justin Wells
- Department of Pathology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814 USA
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Tribble DR, Rodriguez CJ, Weintrob AC, Shaikh F, Aggarwal D, Carson ML, Murray CK, Masuoka P. Environmental Factors Related to Fungal Wound Contamination after Combat Trauma in Afghanistan, 2009-2011. Emerg Infect Dis 2016; 21:1759-69. [PMID: 26401897 PMCID: PMC4593427 DOI: 10.3201/eid2110.141759] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Environmental characteristics, along with known risk factors, may help predict likelihood of mold contamination after injury. During the recent war in Afghanistan (2001–2014), invasive fungal wound infections (IFIs) among US combat casualties were associated with risk factors related to the mechanism and pattern of injury. Although previous studies recognized that IFI patients primarily sustained injuries in southern Afghanistan, environmental data were not examined. We compared environmental conditions of this region with those of an area in eastern Afghanistan that was not associated with observed IFIs after injury. A larger proportion of personnel injured in the south (61%) grew mold from wound cultures than those injured in the east (20%). In a multivariable analysis, the southern location, characterized by lower elevation, warmer temperatures, and greater isothermality, was independently associated with mold contamination of wounds. These environmental characteristics, along with known risk factors related to injury characteristics, may be useful in modeling the risk for IFIs after traumatic injury in other regions.
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Lewandowski LR, Weintrob AC, Tribble DR, Rodriguez CJ, Petfield J, Lloyd BA, Murray CK, Stinner D, Aggarwal D, Shaikh F, Potter BK. Early Complications and Outcomes in Combat Injury-Related Invasive Fungal Wound Infections: A Case-Control Analysis. J Orthop Trauma 2016; 30:e93-9. [PMID: 26360542 PMCID: PMC4761299 DOI: 10.1097/bot.0000000000000447] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Clinicians have anecdotally noted that combat-related invasive fungal wound infections (IFIs) lead to residual limb shortening, additional days and operative procedures before initial wound closure, and high early complication rates. We evaluated the validity of these observations and identified risk factors that may impact time to initial wound closure. DESIGN Retrospective review and case-control analysis. SETTING Military hospitals. PATIENTS/PARTICIPANTS US military personnel injured during combat operations (2009-2011). The IFI cases were identified based on the presence of recurrent, necrotic extremity wounds with mold growth in culture, and/or histopathologic fungal evidence. Non-IFI controls were matched on injury pattern and severity. In a supplemental matching analysis, non-IFI controls were also matched by blood volume transfused within 24 hours of injury. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Amputation revision rate and loss of functional levels. RESULTS Seventy-one IFI cases (112 fungal-infected extremity wounds) were identified and matched to 160 control patients (315 non-IFI extremity wounds). The IFI wounds resulted in significantly more changes in amputation level (P < 0.001). Additionally, significantly (P < 0.001) higher number of operative procedures and longer duration to initial wound closure were associated with IFI. A shorter duration to initial wound closure was significantly associated with wounds lacking IFIs (Hazard ratio: 1.53; 95% confidence interval, 1.17-2.01). The supplemental matching analysis found similar results. CONCLUSIONS Our analysis indicates that IFIs adversely impact wound healing and patient recovery, requiring more frequent proximal amputation revisions and leading to higher early complication rates. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Louis R. Lewandowski
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Amy C. Weintrob
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Carlos J. Rodriguez
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
| | - Joseph Petfield
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234
| | | | - Clinton K. Murray
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, JBSA Fort Sam Houston, TX 78234
| | - Daniel Stinner
- Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD 20817
| | - Benjamin K. Potter
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD 20814
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814
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Lessons of war: Combat-related injury infections during the Vietnam War and Operation Iraqi and Enduring Freedom. J Trauma Acute Care Surg 2016; 79:S227-35. [PMID: 26406435 DOI: 10.1097/ta.0000000000000768] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gordon W, Kuhn K, Staeheli G, Dromsky D. Challenges in definitive fracture management of blast injuries. Curr Rev Musculoskelet Med 2015; 8:290-7. [PMID: 26104316 PMCID: PMC4596208 DOI: 10.1007/s12178-015-9286-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The United States military remains engaged in the longest armed conflict in this nation's history. The majority of casualties in the global war on terror come from blast-related injuries. Multiple centers have published their experience and outcomes with these complex patients. Findings from the study of injured military personnel have implications for mass casualty events resulting from industrial accidents or terrorism in the civilian sector. This article will review the pathophysiology of blast-related injury. The authors will summarize treatment considerations, priorities, and techniques that have proven successful. Finally, the authors will discuss the incidence and management of common complications after blast-related injuries.
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Affiliation(s)
- Wade Gordon
- />Walter Reed National Military Medical Center, Bethesda, MD USA
| | - Kevin Kuhn
- />Naval Medical Center San Diego, San Diego, CA USA
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Radowsky JS, Brown TS, Lisboa FA, Rodriguez CJ, Forsberg JA, Elster EA. Serum Inflammatory Cytokine Markers of Invasive Fungal Infection in Previously Immunocompetent Battle Casualties. Surg Infect (Larchmt) 2015; 16:526-32. [PMID: 26110227 DOI: 10.1089/sur.2013.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive fungal infection (IFI) is described increasingly in individuals experiencing high-energy military trauma. Hallmarks of successful treatment involve aggressive surgical debridement and early initiation of systemic antimicrobial therapy. Currently, intravenous anti-fungal therapy commences based on appearance of wounds and patient's clinical course. Whereas some clinical protocols exist to predict which critically injured patients should receive anti-fungal therapies, there are no established serum markers associated with IFI. Our hypothesis is that serum inflammatory cytokines exist that can assist in identifying individuals at risk for IFI. METHODS This is a retrospective case control study at a single institution. Nine patients with IFI (Saksenaea vasiformis, Fusarium sp., Graphium sp., Scedosporium sp., Aspergillus sp., Mucor sp., and Alternaria sp.) after battlefield trauma were matched to nine individuals with similar injury patterns whose laboratory results were negative for IFI. The combination of serum inflammatory cytokines from the first and second debridements was examined with multiplex platform proteomic analysis. We defined statistical significance as a two-tailed α<0.05 after adjusting for multiple comparisons using the false discovery rate method. This model was refined further with correlation-based filter selection and the area under the curve of the receiver operating characteristics (AUROC) was tested. RESULTS Both groups had similar Injury Severity Scores (ISS) (mean±standard deviation [SD]) (26.8±15.5 vs. 29.2±16.8, p=0.766). Elevated RANTES (regulated on activation, normal T cell expressed and secreted) alone (10,492.8±4,450.1 vs. 5,333.3±4,162.2, p=0.006) correlated with IFI. Also, the combination of persistent elevations in RANTES, interleukin (IL)-2R, and IL-15 was a robust model for predicting IFI with the AUROC being 0.9. CONCLUSIONS Elevation in serum cytokines, particularly RANTES, correlated with IFI in this small group of patients. This demonstrates the potential of future rapid serum testing for early initiation and guidance of anti-fungal therapies.
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Affiliation(s)
- Jason S Radowsky
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Trevor S Brown
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Felipe A Lisboa
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Carlos J Rodriguez
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Jonathan A Forsberg
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,3 Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Eric A Elster
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
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Impact of Mucorales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections. J Clin Microbiol 2015; 53:2262-70. [PMID: 25972413 DOI: 10.1128/jcm.00835-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/05/2015] [Indexed: 11/20/2022] Open
Abstract
Combat trauma wounds with invasive fungal infections (IFIs) are often polymicrobial with fungal and bacterial growth, but the impact of the wound microbiology on clinical outcomes is uncertain. Our objectives were to compare the microbiological features between IFI and non-IFI wounds and evaluate whether clinical outcomes differed among IFI wounds based upon mold type. Data from U.S. military personnel injured in Afghanistan with IFI wounds were examined. Controls were matched by the pattern/severity of injury, including blood transfusion requirements. Wound closure timing was compared between IFI and non-IFI control wounds (with/without bacterial infections). IFI wound closure was also assessed according to mold species isolation. Eighty-two IFI wounds and 136 non-IFI wounds (63 with skin and soft tissue infections [SSTIs] and 73 without) were examined. The time to wound closure was longer for the IFI wounds (median, 16 days) than for the non-IFI controls with/without SSTIs (medians, 12 and 9 days, respectively; P < 0.001). The growth of multidrug-resistant Gram-negative rods was reported among 35% and 41% of the IFI and non-IFI wounds with SSTIs, respectively. Among the IFI wounds, times to wound closure were significantly longer for wounds with Mucorales growth than for wounds with non-Mucorales growth (median, 17 days versus 13 days; P < 0.01). When wounds with Mucorales and Aspergillus spp. growth were compared, there was no significant difference in wound closure timing. Trauma wounds with SSTIs were often polymicrobial, yet the presence of invasive molds (predominant types: order Mucorales, Aspergillus spp., and Fusarium spp.) significantly prolonged the time to wound closure. Overall, the times to wound closure were longest for the IFI wounds with Mucorales growth.
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Combat-Related Pythium aphanidermatum Invasive Wound Infection: Case Report and Discussion of Utility of Molecular Diagnostics. J Clin Microbiol 2015; 53:1968-75. [PMID: 25832301 DOI: 10.1128/jcm.00410-15] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/26/2015] [Indexed: 11/20/2022] Open
Abstract
We describe a 22-year-old soldier with 19% total body surface area burns, polytrauma, and sequence- and culture-confirmed Pythium aphanidermatum wound infection. Antemortem histopathology suggested disseminated Pythium infection, including brain involvement; however, postmortem PCR revealed Cunninghamella elegans, Lichtheimia corymbifera, and Saksenaea vasiformis coinfection. The utility of molecular diagnostics in invasive fungal infections is discussed.
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Blyth DM, Mende K, Weintrob AC, Beckius ML, Zera WC, Bradley W, Lu D, Tribble DR, Murray CK. Resistance patterns and clinical significance of Candida colonization and infection in combat-related injured patients from iraq and afghanistan. Open Forum Infect Dis 2014; 1:ofu109. [PMID: 25734177 PMCID: PMC4324214 DOI: 10.1093/ofid/ofu109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/12/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and outcomes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. METHODS Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009-October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Susceptibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Standards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. RESULTS The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albicans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghanistan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. CONCLUSIONS Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate.
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Affiliation(s)
- Dana M. Blyth
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Katrin Mende
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - Amy C. Weintrob
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
- Infectious Disease, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Miriam L. Beckius
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
| | - Wendy C. Zera
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - William Bradley
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - Dan Lu
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences
| | - Clinton K. Murray
- Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas
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Clinical relevance of mold culture positivity with and without recurrent wound necrosis following combat-related injuries. J Trauma Acute Care Surg 2014; 77:769-773. [PMID: 25494431 DOI: 10.1097/ta.0000000000000438] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Invasive fungal wound infections (IFIs) are a recognized threat for personnel who sustain combat-related blast trauma in Afghanistan. Blast trauma, particularly when dismounted, has wounds contaminated with organic debris and potential for mold infection. Trauma-associated IFI is characterized by recurrent wound necrosis on serial debridement with histologic evidence of invasive molds and/or fungal culture growth. Wounds with mold growth but lacking corresponding recurrent necrosis present a clinical dilemma of whether to initiate antifungal treatment. Our objective was to assess the clinical significance of fungal culture growth without recurrent wound necrosis. METHODS US military personnel wounded during combat in Afghanistan (June 2009 to August 2011) were assessed for growth of mold from wound cultures and/or histopathologic evidence of IFI. Identified patients were stratified based on clinical wound appearance (with/without recurrent necrosis), and the resultant groups were compared for injury characteristics, clinical management, and outcomes. RESULTS A total of 96 patients were identified: 77 with fungal elements on histopathology and/or fungal growth plus recurrent wound necrosis and 19 with fungal growth on culture but no wound necrosis after initial debridements. Injury patterns and severity were similar between the groups. Patients with recurrent necrosis had more frequent fevers and leukocytosis during the first 2 weeks after injury, and the majority received antifungal therapy compared with only three patients (16%) without recurrently necrotic wounds. Overall, patients without recurrent wound necrosis had significantly less operative procedures (p = 0.02), shorter stay in the intensive care unit (p < 0.01), and lower rates of high-level amputations (5% vs. 20%) and deaths (none vs. 8%) despite no or infrequent antifungal use. CONCLUSION The finding of molds on wound culture among patients with blast trauma in the absence of recurrently necrotic wounds on serial debridement does not require systemic antifungal chemotherapy. LEVEL OF EVIDENCE Therapeutic study, level IV. Prognosti/epidemiologic study, level III.
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Abstract
Combat-related invasive fungal (mold) wound infections (IFIs) have emerged as an important and morbid complication following explosive blast injuries among military personnel. Similar to trauma-associated IFI cases among civilian populations, as in agricultural accidents and natural disasters, these infections occur in the setting of penetrating wounds contaminated by environmental debris. Specific risk factors for combat-related IFI include dismounted (patrolling on foot) blast injuries occurring mostly in southern Afghanistan, resulting in above knee amputations requiring resuscitation with large-volume blood transfusions. Diagnosis of IFI is based upon early identification of a recurrently necrotic wound following serial debridement and tissue-based histopathology examination with special stains to detect invasive disease. Fungal culture of affected tissue also provides supportive information. Aggressive surgical debridement of affected tissue is the primary therapy. Empiric antifungal therapy should be considered when there is a strong suspicion for IFI. Both liposomal amphotericin B and voriconazole should be considered initially for treatment since many of the cases involve not only Mucorales species but also Aspergillus or Fusarium spp., with narrowing of regimen based upon clinical mycology findings.
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