509 Fungal Infections After Blast and Thermal Injury

Abstract

Abstract Introduction Invasive fungal wound infections have been reported after combat-related blast injury sustained in recent conflicts. Systemic antifungal agents are commonly used as an adjunct to urgent surgical debridement. There is currently controversy in defining the depth of fungal invasion, which is the most critical factor that determines the treatment strategy. The objective of this study was to describe fungal infections in blast injury patients admitted to our burn center. Methods This was a retrospective chart review. Subjects who were admitted between January 2004 and February 2019, received a systemic antifungal agent, and experienced a blast injury were included. Culture and histopathology results were recorded. Results Eighty one patients were included. Seventy five subjects (92.6%) were active-duty service members at the time of injury and 79 (97.5%) subjects were male. On average, subjects were 27.4±7.8 years old with a burn size of 51.4±25.3% TBSA. Twenty seven subjects (33.3%) died during their hospital stay. The 75 subjects had 157 cultures positive for fungi, including 130 tissue cultures. The most common genera isolated was Aspergillus (n=148), Candida (n=106), Fusarium (n=16), and Mucor (n=12). Fifty seven percent of subjects who grew Mucor died, as compared to 52% who grew Aspergillus, 50% who grew Fusarium, and 32.3% who grew Candida. For histopathology, 33 subjects (40.7%) had results with fungus in non-viable tissue, 27 subjects (25.9%) had results with fungus in viable tissue, and 14 (17.3%) had results with angioinvasion. Subjects who had fungus in viable tissue had the highest mortality rate (71.4%), followed by angioinvasion (64.3%), and fungus in non-viable tissue (33.3%). The 75 subjects received 121 courses of systemic antifungals. The average duration of therapy was 12.3±13.6 days. The most common antifungals ordered were voriconazole (n=58), fluconazole (n=53), and liposomal amphotericin B (n=42). Conclusions Invasive fungal infection after blast injury had a high mortality rate. Early recognition and management of fungal infections is paramount to patient survival. A consensus is needed on how to best define the depth and level of invasion of fungal wound infections, and to determine the optimal treatment duration of systemic antifungal agents for these patients. Applicability of Research to Practice Invasive fungal wound infections carry a high mortality rate. A consensus is needed on the optimal systemic therapy.