Two Mine Resistant Ambush Protected vehicles from the 883rd Engineer Battalion make their way down a main supply route in Afghanistan in search of improvised explosive devices this past February.

BETHESDA, MD--Invasive fungal wound infections are on the increase in military personnel wounded by improvised explosive devices, leading to significant morbidity and even death in some cases where the victims initially survived.

David R. Tribble, MD, of the Uniformed Services University of the Health Sciences, and colleagues report in the journal Clinical Infectious Diseases that IEDs can cause gross contamination of wounds. According to the published correspondence, researchers looked at 2,413 patients wounded in Afghanistan and moved via Landstuhl Regional Medical Center in Germany to one of four U.S. military hospitals between 2009 and 2010.

Of 37 cases identified, 20 had proven fungal wound infections, four were probable and 13 were possible. The rates reached 3.5% of trauma admissions in late 2010.

All of the cases were related to blast injury, with 92% of them occurring during foot patrols in southern Afghanistan.  Some 80% involved lower extremity amputation, and nearly all required large volume blood transfusions .  Mold isolates were recovered in 83% of cases.

Clinical outcomes included three deaths, 11 cases where frequent debridements were required and amputation revisions in 58% of cases, according to the report. Antifungal therapy was employed in nearly 90% of the patients, including lipid formulations of amphotericin Bs, voriconazole, and posaconazole.

 “Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma,” the authors write. “Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity.”

The authors point out that awareness of the likely factors leading to invasive fungal wound infections can help field clinicians better identify them.

“IFIs are an emerging trauma-related infection leading to significant morbidity,” they write. “Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds.”