Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries

Bradley Lloyd, Amy C. Weintrob, Carlos Rodriguez, James R. Dunne, Allison B. Weisbrod, Mary Hinkle, Tyler Warkentien, Clinton K. Murray, John Oh, Eugene V. Millar, Jinesh Shah, Faraz Shaikh, Stacie Gregg, Gina Lloyd, Julie Stevens, M. Leigh Carson, Deepak Aggarwal, David R. Tribble

Research output: Contribution to journalArticle

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Abstract

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.

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).

Original languageEnglish (US)
Pages (from-to)619-626
Number of pages8
JournalSurgical Infections
Volume15
Issue number5
DOIs
StatePublished - Oct 1 2014

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Blast Injuries
Practice Guidelines
Invasive Fungal Infections
Early Diagnosis
Afghanistan
Injury Severity Score

All Science Journal Classification (ASJC) codes

  • Surgery
  • Microbiology (medical)
  • Infectious Diseases

Cite this

Lloyd, B., Weintrob, A. C., Rodriguez, C., Dunne, J. R., Weisbrod, A. B., Hinkle, M., ... Tribble, D. R. (2014). Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries. Surgical Infections, 15(5), 619-626. https://doi.org/10.1089/sur.2012.245
Lloyd, Bradley ; Weintrob, Amy C. ; Rodriguez, Carlos ; Dunne, James R. ; Weisbrod, Allison B. ; Hinkle, Mary ; Warkentien, Tyler ; Murray, Clinton K. ; Oh, John ; Millar, Eugene V. ; Shah, Jinesh ; Shaikh, Faraz ; Gregg, Stacie ; Lloyd, Gina ; Stevens, Julie ; Carson, M. Leigh ; Aggarwal, Deepak ; Tribble, David R. / Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries. In: Surgical Infections. 2014 ; Vol. 15, No. 5. pp. 619-626.
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abstract = "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.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).",
author = "Bradley Lloyd and Weintrob, {Amy C.} and Carlos Rodriguez and Dunne, {James R.} and Weisbrod, {Allison B.} and Mary Hinkle and Tyler Warkentien and Murray, {Clinton K.} and John Oh and Millar, {Eugene V.} and Jinesh Shah and Faraz Shaikh and Stacie Gregg and Gina Lloyd and Julie Stevens and Carson, {M. Leigh} and Deepak Aggarwal and Tribble, {David R.}",
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Lloyd, B, Weintrob, AC, Rodriguez, C, Dunne, JR, Weisbrod, AB, Hinkle, M, Warkentien, T, Murray, CK, Oh, J, Millar, EV, Shah, J, Shaikh, F, Gregg, S, Lloyd, G, Stevens, J, Carson, ML, Aggarwal, D & Tribble, DR 2014, 'Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries', Surgical Infections, vol. 15, no. 5, pp. 619-626. https://doi.org/10.1089/sur.2012.245

Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries. / Lloyd, Bradley; Weintrob, Amy C.; Rodriguez, Carlos; Dunne, James R.; Weisbrod, Allison B.; Hinkle, Mary; Warkentien, Tyler; Murray, Clinton K.; Oh, John; Millar, Eugene V.; Shah, Jinesh; Shaikh, Faraz; Gregg, Stacie; Lloyd, Gina; Stevens, Julie; Carson, M. Leigh; Aggarwal, Deepak; Tribble, David R.

In: Surgical Infections, Vol. 15, No. 5, 01.10.2014, p. 619-626.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries

AU - Lloyd, Bradley

AU - Weintrob, Amy C.

AU - Rodriguez, Carlos

AU - Dunne, James R.

AU - Weisbrod, Allison B.

AU - Hinkle, Mary

AU - Warkentien, Tyler

AU - Murray, Clinton K.

AU - Oh, John

AU - Millar, Eugene V.

AU - Shah, Jinesh

AU - Shaikh, Faraz

AU - Gregg, Stacie

AU - Lloyd, Gina

AU - Stevens, Julie

AU - Carson, M. Leigh

AU - Aggarwal, Deepak

AU - Tribble, David R.

PY - 2014/10/1

Y1 - 2014/10/1

N2 - 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.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).

AB - 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.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).

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