Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries.
BACKGROUND
An outbreak of invasive fungal infections (IFI) began in 2009 among United States servicemen who sustained blast injuries in Afghanistan. In response, the military trauma community sought a uniform approach to early diagnosis and treatment. Toward this goal, a local clinical practice guideline (CPG) was implemented at Landstuhl Regional Medical Center (LRMC) in early 2011 to screen for IFI in high-risk patients using tissue histopathology and fungal cultures.


METHODS
We compared IFI cases identified after initiation of the CPG (February through August 2011) to cases from a pre-CPG period (June 2009 through January 2011).


RESULTS
Sixty-one patients were screened in the CPG period, among whom 30 IFI cases were identified and compared with 44 pre-CPG IFI cases. Demographics between the two study periods were similar, although significantly higher transfusion requirements (p<0.05) and non-significant trends in injury severity scores and early lower extremity amputation rates suggested more severe injuries in CPG-period cases. Pre-CPG IFI cases were more likely to be associated with angioinvasion on histopathology than CPG IFI cases (48% versus 17%; p<0.001). Time to IFI diagnosis (three versus nine days) and to initiation of antifungal therapy (seven versus 14 days) were significantly decreased in the CPG period (p<0.001). Additionally, more IFI patients received antifungal agent at LRMC during the CPG period (30%) versus pre-CPG period (5%; p=0.005). The CPG IFI cases were also prescribed more commonly dual antifungal therapy (73% versus 36%; p=0.002). There was no statistical difference in length of stay or mortality between pre-CPG and CPG IFI cases; although a non-significant reduction in crude mortality from 11.4% to 6.7% was observed.


CONCLUSIONS
Angioinvasive IFI as a percentage of total IFI cases decreased during the CPG period. Earlier diagnosis and commencement of more timely treatment was achieved. Despite these improvements, no difference in clinical outcomes was observed compared with the pre-CPG period.
1 Landstuhl Regional Medical Center , Landstuhl, Germany .
Bradley
B
Lloyd
Amy C
AC
Weintrob
Carlos
C
Rodriguez
James R
JR
Dunne
Allison B
AB
Weisbrod
Mary
M
Hinkle
Tyler
T
Warkentien
Clinton K
CK
Murray
John
J
Oh
Eugene V
EV
Millar
Jinesh
J
Shah
Faraz
F
Shaikh
Stacie
S
Gregg
Gina
G
Lloyd
Julie
J
Stevens
M Leigh
ML
Carson
Deepak
D
Aggarwal
David R
DR
Tribble
D000328:Adult; D055826:Afghan Campaign 2001-; D000935:Antifungal Agents / Q000008:administration & dosage; D001753:Blast Injuries / Q000453:epidemiology / Q000382:microbiology*; D006801:Humans; D008297:Male; D008889:Military Personnel / Q000706:statistics & numerical data*; D009181:Mycoses / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
D000935:Antifungal Agents