title: Early Complications and Outcomes in Combat Injury-Related Invasive Fungal Wound Infections: A Case-Control Analysis.
abstract: OBJECTIVE
  Clinicians have anecdotally noted that combat-related invasive fungal wound infections (IFIs) lead to residual limb shortening, additional days and operative procedures before initial wound closure, and high early complication rates. We evaluated the validity of these observations and identified risk factors that may impact time to initial wound closure.
  
  
  METHODS
  Retrospective review and case-control analysis.
  
  
  METHODS
  Military hospitals.
  
  
  METHODS
  US military personnel injured during combat operations (2009-2011). The IFI cases were identified based on the presence of recurrent, necrotic extremity wounds with mold growth in culture, and/or histopathologic fungal evidence. Non-IFI controls were matched on injury pattern and severity. In a supplemental matching analysis, non-IFI controls were also matched by blood volume transfused within 24 hours of injury.
  
  
  METHODS
  None.
  
  
  METHODS
  Amputation revision rate and loss of functional levels.
  
  
  RESULTS
  Seventy-one IFI cases (112 fungal-infected extremity wounds) were identified and matched to 160 control patients (315 non-IFI extremity wounds). The IFI wounds resulted in significantly more changes in amputation level (P < 0.001). Additionally, significantly (P < 0.001) higher number of operative procedures and longer duration to initial wound closure were associated with IFI. A shorter duration to initial wound closure was significantly associated with wounds lacking IFIs (Hazard ratio: 1.53; 95% confidence interval, 1.17-2.01). The supplemental matching analysis found similar results.
  
  
  CONCLUSIONS
  Our analysis indicates that IFIs adversely impact wound healing and patient recovery, requiring more frequent proximal amputation revisions and leading to higher early complication rates.
  
  
  METHODS
  Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: *Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD; †Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; ‡Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD; §The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD; ‖Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX; ¶Landstuhl Regional Medical Center, Landstuhl, Germany; and **Infectious Disease Service, San Antonio Military Medical Center, Houston, TX (B. A. Lloyd is now with San Antonio Military Medical Center, JBSA Fort Sam Houston, TX).
authors.forename: Louis R
authors.initials: LR
authors.lastname: Lewandowski
authors.forename: Amy C
authors.initials: AC
authors.lastname: Weintrob
authors.forename: David R
authors.initials: DR
authors.lastname: Tribble
authors.forename: Carlos J
authors.initials: CJ
authors.lastname: Rodriguez
authors.forename: Joseph
authors.initials: J
authors.lastname: Petfield
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Lloyd
authors.forename: Clinton K
authors.initials: CK
authors.lastname: Murray
authors.forename: Daniel
authors.initials: D
authors.lastname: Stinner
authors.forename: Deepak
authors.initials: D
authors.lastname: Aggarwal
authors.forename: Faraz
authors.initials: F
authors.lastname: Shaikh
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Potter
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D016022:Case-Control Studies; D015984:Causality; D015897:Comorbidity; D005260:Female; D006801:Humans; D008297:Male; D008889:Military Personnel / Q000706:statistics & numerical data*; D009181:Mycoses; D015995:Prevalence; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000628:therapy*; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000453:epidemiology* / Q000628:therapy*; D055815:Young Adult