Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification

Abstract

The emergence of invasive fungal wound infections (IFIs) in combat casualties led to development of a combat trauma-specific IFI case definition and classification. Prospective data were collected from 1133 US military personnel injured in Afghanistan (June 2009-August 2011). The IFI rates ranged from 0·2% to 11·7% among ward and intensive care unit admissions, respectively (6·8% overall). Seventy-seven IFI cases were classified as proven/probable (n = 54) and possible/unclassifiable (n = 23) and compared in a case-case analysis. There was no difference in clinical characteristics between the proven/probable and possible/unclassifiable cases. Possible IFI cases had shorter time to diagnosis (P = 0·02) and initiation of antifungal therapy (P = 0·05) and fewer operative visits (P = 0·002) compared to proven/probable cases, but clinical outcomes were similar between the groups. Although the trauma-related IFI classification scheme did not provide prognostic information, it is an effective tool for clinical and epidemiological surveillance and research.

Fig. 1

[colour online]. Flow diagram showing the eligible study population and resulting invasive fungal infection (IFI) cases from the total number of Landstuhl Regional Medical Center (LRMC) trauma admissions. Factors triggering review of data for IFI diagnosis were wound culture with fungal growth, pathology with fungal elements, or administration of ⩾2 days of antifungal agents. Confirmation of IFI diagnosis required recurrent wound tissue necrosis following two or more surgical debridements in addition to the presence of tissue invasion with fungal hyphae angioinvasion (proven classification), histopathological fungal elements (probable classification), and/or fungal growth on culture (possible classification). Unclassifiable IFIs are cases with fungal culture evidence, but histopathology was not sent for evaluation; therefore, they are not able to be specified to a specific classification on the basis of the available evidence. ICU, Intensive care unit; MTF, military treatment facility; TIDOS, Trauma Infectious Disease Outcomes Study.

Fig. 2

[colour online]. Boxplots of (a) maximum white blood cell (WBC, 10⁹ cells/l) counts and (b) maximum weekly temperatures (°C) among US military personnel injured in combat (2009–2011). Weekly data combined from Landstuhl Regional Medical Center and US military treatment facilities.