title: Clinical relevance of mold culture positivity with and without recurrent wound necrosis following combat-related injuries.
abstract: BACKGROUND
  Invasive fungal wound infections (IFIs) are a recognized threat for personnel who sustain combat-related blast trauma in Afghanistan. Blast trauma, particularly when dismounted, has wounds contaminated with organic debris and potential for mold infection. Trauma-associated IFI is characterized by recurrent wound necrosis on serial debridement with histologic evidence of invasive molds and/or fungal culture growth. Wounds with mold growth but lacking corresponding recurrent necrosis present a clinical dilemma of whether to initiate antifungal treatment. Our objective was to assess the clinical significance of fungal culture growth without recurrent wound necrosis.
  
  
  METHODS
  US military personnel wounded during combat in Afghanistan (June 2009 to August 2011) were assessed for growth of mold from wound cultures and/or histopathologic evidence of IFI. Identified patients were stratified based on clinical wound appearance (with/without recurrent necrosis), and the resultant groups were compared for injury characteristics, clinical management, and outcomes.
  
  
  RESULTS
  A total of 96 patients were identified: 77 with fungal elements on histopathology and/or fungal growth plus recurrent wound necrosis and 19 with fungal growth on culture but no wound necrosis after initial debridements. Injury patterns and severity were similar between the groups. Patients with recurrent necrosis had more frequent fevers and leukocytosis during the first 2 weeks after injury, and the majority received antifungal therapy compared with only three patients (16%) without recurrently necrotic wounds. Overall, patients without recurrent wound necrosis had significantly less operative procedures (p = 0.02), shorter stay in the intensive care unit (p < 0.01), and lower rates of high-level amputations (5% vs. 20%) and deaths (none vs. 8%) despite no or infrequent antifungal use.
  
  
  CONCLUSIONS
  The finding of molds on wound culture among patients with blast trauma in the absence of recurrently necrotic wounds on serial debridement does not require systemic antifungal chemotherapy.
  
  
  METHODS
  Therapeutic study, level IV. Prognosti/epidemiologic study, level III.
authors.affiliation: From the Walter Reed National Military Medical Center (C.R., A.C.W., A.B.W., T.W., D.M., J.W.); and Infectious Disease Clinical Research Program (A.C.W., W.B., F.S., J.S., M.L.C., D.A., D.R.T.), and Department of Surgery (J.R.D.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; and San Antonio Military Medical Center (C.K.M.), Fort Sam Houston, San Antonio, Texas; and Bradley Lloyd, DO, Landstuhl Regional Medical Center (B.L.), Landstuhl, Germany.
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