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Risk factors associated with invasive fungal infections in combat trauma
Carlos J Rodriguez1, Amy C Weintrob, Jinesh Shah
11 Walter Reed National Military Medical Center , Bethesda, Maryland.
Background:
In recent years, invasive fungal infections (IFI) have complicated the clinical course of patients with combat-related injuries. Commonalities in injury patterns and characteristics among patients with IFI led to the development of a Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management. We performed a case-control study to confirm and further delineate risk factors associated with IFI development in combat casualties with the objective of generating data to refine the CPG and promote timelier initiation of treatment.
Methods:
Data were collected retrospectively for United States (U.S.) military personnel injured during deployment in Afghanistan from June 2009 through August 2011. Cases were identified as IFI based upon wound cultures with fungal growth and/or fungal elements seen on histology, in addition to the presence of recurrent wound necrosis. Controls were matched using date of injury (±3 mo) and injury severity score (±10). Risk factor parameters analyzed included injury circumstances, blood transfusion requirements, amputations after first operative intervention, and associated injuries. Data are expressed as multivariate odds ratios (OR; 95% confidence interval [CI]).
Results:
Seventy-six IFI cases were identified from 1,133 U.S. military personnel wounded in Afghanistan and matched to 150 controls. Parameters associated significantly with the development of IFI multivariate analysis were blast injuries (OR: 5.7; CI: 1.1-29.6), dismounted at time of injury (OR: 8.5; CI: 1.2-59.8); above the knee amputations (OR: 4.1; CI: 1.3-12.7), and large-volume packed red blood cell (PRBC; >20 U) transfusions within first 24 h (OR: 7.0; CI: 2.5-19.7).
Conclusions:
Our analysis indicates that dismounted blast injuries, resulting in above the knee amputations, and requirement of large volume PRBC transfusions are independent predictors of IFI development. These data confirm all the preliminary risk factors, except for genitalia/perineal injuries, utilized by JTS in their IFI CPG. Model validation is necessary for further risk factor specification.
Insights
Invasive fungal infections (IFI) in combat casualties are predicted by dismounted blast injuries, above-the-knee amputations, and large packed red blood cell transfusions. These findings refine clinical practice guidelines for timely IFI treatment.
Area of Science:
- Combat medicine
- Infectious diseases
- Trauma surgery
Background:
- Invasive fungal infections (IFI) are a growing concern in patients with combat-related injuries.
- A Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management was developed based on injury patterns.
- This study aimed to refine the IFI CPG by identifying specific risk factors in combat casualties.
Purpose of the Study:
- To identify and delineate independent risk factors for the development of invasive fungal infections (IFI) in combat casualties.
- To generate data for refining the Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management.
- To promote earlier initiation of treatment for IFI in military personnel.
Main Methods:
- Retrospective case-control study of U.S. military personnel injured in Afghanistan (June 2009-August 2011).
- IFI cases identified by wound cultures, histology, and recurrent wound necrosis; controls matched by injury date and severity.
- Analyzed risk factors including blast injuries, dismounted status, amputations, and blood transfusion volume.
Main Results:
- Seventy-six IFI cases were identified and matched with 150 controls.
- Independent predictors of IFI included blast injuries (OR: 5.7), dismounted status (OR: 8.5), above-the-knee amputations (OR: 4.1), and large PRBC transfusions (>20 U) within 24 hours (OR: 7.0).
- These factors were significantly associated with IFI development (p<0.05).
Conclusions:
- Dismounted blast injuries, above-the-knee amputations, and large PRBC transfusions are independent predictors of IFI.
- Findings confirm most preliminary risk factors used in the JTS IFI CPG, excluding genitalia/perineal injuries.
- Further model validation is needed for enhanced risk factor specification in IFI management.
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