Treatment of Suspected Invasive Fungal Infection in War Wounds

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.

Combat-Related Invasive Fungal Infections: Development of a Clinically Applicable Clinical Decision Support System for Early Risk Stratification

“…Following development and validation, the models were deployed on the Surgical Critical Care Initiative (SC2i) website and incorporated into the U.S. Army Institute of Surgical Research Clinical Practice Guidelines 23 to accelerate distribution within the Military Health System (MHS). Presently, the IFI tool is only available to military providers.…”

Molecular Detection of Filamentous Fungi in Formalin-Fixed Paraffin-Embedded Specimens in Invasive Fungal Wound Infections Is Feasible with High Specificity

“…The trade-off between specificity and sensitivity is worth considering. The decision to initiate antifungals for combat casualties is based on easily ascertainable clinical criteria (37), not laboratory findings. Based on current practice guidelines, this approach would involve the use of both amphotericin-based compounds and an azole (37).…”

“…The decision to initiate antifungals for combat casualties is based on easily ascertainable clinical criteria (37), not laboratory findings. Based on current practice guidelines, this approach would involve the use of both amphotericin-based compounds and an azole (37). Although a clinician is unlikely to withhold antifungals when a person meets clinical criteria, a test that allows the clinician to safely withdraw antifungals is desirable (i.e., an assay with high negative predictive value, which was noted with panfungal PCR in specimens with angioinvasion).…”

Mould Infections of Traumatic Wounds: A Brief Narrative Review

“…For example, combinations of Mucorales, Aspergillus spp., and Fusarium spp. have been found in an observational cohort study of infectious complications among military personnel injured during war in Iraq and Afghanistan [64]. Furthermore, post-traumatic wounds can also be infected with bacteria; thus, an antibiotic treatment should also be promptly started empirically and revaluated according to the course of the disease and laboratory results [25].…”

“…Classical laboratory techniques for the diagnosis of post-traumatic mould infections. Diagnostic criteria for invasive fungal diseases in war wounds are: (1) traumatic wound; (2) recurrent necrosis after at least two consecutive debridements; (3) positive laboratory results (i.e., positivity of mould culture and/or histological evidence of tissue invasion)[21,64] …”