Treatment of Suspected Invasive Fungal Infection in War Wounds

• Published in: Military medicine Vol. 183; no. suppl_2; pp. 142 - 146
• Main Authors: Rodriguez, Carlos J, Tribble, David R, Malone, Debra L, Murray, Clinton K, Jessie, Elliot M, Khan, Mansoor, Fleming, Mark E, Potter, Benjamin K, Gordon, Wade T, Shackelford, Stacy A
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 01-09-2018
• Subjects: Administration, Topical; Afghan Campaign 2001; Amphotericin B - therapeutic use; Amputation; Antifungal Agents - therapeutic use; beta-Cyclodextrins - therapeutic use; Blood; Debridement - methods; Disease prevention; Excipients; Fungal infections; Histopathology; Humans; Infectious diseases; Injuries; Mortality; Mycoses - diagnosis; Mycoses - drug therapy; Patients; Recurrence; Risk Factors; Tobramycin - therapeutic use; Trauma; Treatment Outcome; Triazoles - therapeutic use; Vancomycin - therapeutic use; Voriconazole - therapeutic use; Wounds and Injuries - complications; Wounds and Injuries - drug therapy; Afghanistan
• ISSN: 0026-4075; 1930-613X
• DOI: 10.1093/milmed/usy079

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.