Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Resistance Patterns and Clinical Significance of Candida Colonization and Infection in Combat-Related Injured Patients From Iraq and Afghanistan

Resistance Patterns and Clinical Significance of Candida Colonization and Infection in... MA JO R A R T IC LE Resistance Patterns and Clinical Significance of Candida Colonization and Infection in Combat- Related Injured Patients From Iraq and Afghanistan 1 1,2,3 2,3,4 1 1,2,3 1,2,3 Dana M. Blyth, Katrin Mende, Amy C. Weintrob, Miriam L. Beckius, Wendy C. Zera, William Bradley, 2,3 2 1 Dan Lu, David R. Tribble, and Clinton K. Murray ; the Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group 1 2 Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas; Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and Infectious Disease, Walter Reed National Military Medical Center, Bethesda, Maryland Background. Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and out- comes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. Methods. Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009–October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Suscep- tibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Stan- dards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. Results. The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albi- cans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghan- istan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. Conclusions. Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate. Keywords. antifungal resistance; Candida; combat-related trauma. Introduction Received 10 October 2014; accepted 12 November 2014. Correspondence: Clinton K. Murray, MD, Chief, Infectious Disease Service, Natural disasters and manmade bombings have been Department of the Army, San Antonio Military Medical Center, MCHE-MDI, 3551 Roger Brooke Drive, JBSA-Fort Sam Houston, TX 78234-6200 (clinton.k.murray. associated with both multidrug-resistant (MDR) bacte- mil@mail.mil). rial infections and invasive mold wound infections Open Forum Infectious Diseases (MWIs) [1–7]. The risk factors and role of Candida spp © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Societyof America. This is an Open Access article distributed under the terms colonization and infection in these patients with penetrat- of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http:// ing trauma (eg, open wound contaminated by environ- creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work mental and/or organic debris) is unclear. Prior studies is not altered or transformed in any way, and that the work is properly cited. For have shown high rates of candidemia after a bomb ex- commercial re-use, please contact journals.permissions@oup.com. DOI: 10.1093/ofid/ofu109 plosion in a market [8] and Candida wound infections Candida Relevance in Combat Casualties OFID 1 � � complicating cluster bomb injuries [9]. Among trauma patients Combat-related injuries were characterized using both Injury with penetrating injuries related to natural disasters, rates of Severity Score (ISS) [18] and Abbreviated Injury Scale 2005- wound infections with Candida may be as high as 20% [1]. Military (AIS) [19, 20]. Wound AIS was defined as the AIS In recent years, there has also been a move towards harmo- score for the area of a wound or intra-abdominal culture. nizing Clinical Laboratory and Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing Candida Species Isolate Analysis (EUCAST) antifungal susceptibility testing (AST) [10]; howev- As part of TIDOS, after identification and susceptibility testing er, differences in procedures and interpretative breakpoints re- per standard procedures at clinical sites, bacterial and yeast iso- main [11–13]. Commercial AST is increasingly used in clinical lates are archived for future study at −80°C. We used all initial laboratories, and performance has been variably studied against unique and serial (≥7 days between same species) Candida iso- the new CLSI and EUCAST breakpoints [14, 15]. There are also lates. Archived isolates were passaged twice on sabouraud dex- increasing concerns regarding changes in Candida spp distribu- trose agar before further testing. The BD Phoenix Automated tions, resistance, and correlation of breakpoints with clinical Microbiology System (BD Diagnostics, Sparks, MD) was used outcomes. to confirm or determine Candida species as necessary. Sensititre In this study, we sought to identify clinical characteristics and YeastOne (YO-9) (TREK Diagnostic Systems, Cleveland, OH) outcomes associated with Candida spp colonization and infec- plates were used for broth microdilution susceptibility testing tion in deployment-related injured personnel in Iraq and [14, 21–23]. Antifungal agents analyzed included anidulafungin, Afghanistan. We also examined Candida spp distributions micafungin, caspofungin, 5-flucytosine, posaconazole, vorico- and resistance patterns according to CLSI and EUCAST nazole, itraconazole, fluconazole, and amphotericin B. breakpoints. For CLSI interpretations, AST for Candida albicans, Candida glabrata, Candida tropicalis, Candida krusei, and Candida para- psilosis were interpreted according to M27-S4 breakpoints [11]. METHODS Candida spp breakpoints not specifically addressed in M27-S4 Study Population and Definitions were determined according to M27-S3 breakpoints [24]. Am- The Trauma Infectious Disease Outcomes Study (TIDOS) was photericin susceptibility was determined by M27-A3 break- implemented on June 1, 2009. All patients with isolation of points [25]. The EUCAST breakpoints were determined by Candida spp from initiation of TIDOS to October 26, 2013 EUCAST Antifungal Agents Breakpoint Tables for Interpreta- were included in the analysis. The TIDOS eligibility criteria tion of Minimal Inhibitory Concentrations (MIC), version 6.1 have previously been described and include active duty person- [26]. nel or Department of Defense beneficiaries ≥18 years who are Although EUCAST methods to determine MIC results are injured during deployment requiring evacuation to Landstuhl intended to yield results that are concordant with CLSI proce- Regional Medical Center (LRMC) in Germany and ultimately dures, [12] differences in methodology between AST procedures transferring to a participating clinical site in the United States yield lower breakpoints for anidulafungin and micafungin by [16]. Trauma history, clinical characteristics on admission, EUCAST compared with CLSI [27]. Sensititre YeastOne may course, and outcomes were obtained retrospectively from the also yield higher MICs for select antifungals than the EUCAST TIDOS database. The study was approved by the Infectious Dis- method [28], so our MIC results were normalized against the ease Institutional Review Board of the Uniformed Services Uni- modal MIC and ranges provided by EUCAST rationale docu- versity of the Health Sciences in Bethesda, Maryland. ments [27]. The modal MIC and MIC ranges obtained by the Infectious disease events were classified, as previously de- Sensititre YeastOne were consistent with those obtained by scribed, by a combination of clinical findings, laboratory tests, EUCAST methods for all antifungals tested except anidulafun- clinical diagnosis, and/or initiation of directed antimicrobial gin and posaconazole [29], which were adjusted as appropriate therapy for ≥5days[16]. Cultures were performed at the discre- with breakpoints established 2 dilutions above the respective tion of clinical providers. Isolates associated with infections modal MICs. These modifications yielded the adjusted-EUCAST were collected as part of clinical infection work-ups, whereas interpretations (AEIs). isolates were considered to be colonizers if they were specimens obtained for purposes other than infection work-up (eg, surveil- Statistical Analysis lance). Susceptibility testing was performed by each hospital’s Univariate analysis included χ and Fisher’s exact test for cate- microbiology laboratory and interpreted by CLSI criteria. The gorical variables, as appropriate, and Mann-Whitney U for con- TIDOS database was queried for information on concomitant tinuous variables. A P value of <.05 was used as a significant bacterial and MWI within the cohort. Infections, presence of cutoff. Multivariate analysis was completed with logistic regres- MDR bacteria, and MWI are defined systematically within the sion of pertinent significant risk factors from univariate analy- TIDOS database [3, 5, 16, 17]. sis. Antifungal susceptibility by CLSI and EUCAST were not 2 OFID Blyth et al � � included in multivariate analysis because they were correlated Clinical Findings and Outcomes by Candida Isolates with non-albicans Candida species. Statistical analyses were Of the 127 patients, there were 131 unique Candida isolates. performed using SPSS software (IBM SPSS Statistics Version Onehundred twouniqueisolateswere Calbicans and 29 19, Chicago, IL). were non-albicans Candida spp (Table 2). Seventy-four isolates were associated with infection and 57 were colonizers. The majority of both Calbicans and non-albicans Candida spp RESULTS were collected from personnel injured in Afghanistan (90% and 86%, respectively). Furthermore, the majority of isolates Overall Demographics and Injury Patterns were collected at institutions within the United States (55%) During this time period, 5694 trauma patient evacuations compared with 45% at LRMC. occurred through LRMC, and 2567 patients were transferred Five candidemic patients had prior antifungal exposure with to TIDOS-participating clinical facilities in the United States. a median of 3 days preceding isolation of Candida spp. Thirty- Of these patients, 127 (5%) had Candida species for study one percent of non-albicans Candida isolates and 16% of C al- inclusion. The median age of the patients was 23 years and bicans isolates were from patients who also had MWI. Median 99% were male (Table 1). The majority of injuries were due time from injury to Candida isolation was 6 days for C albicans to blasts (71% related to improvised explosive devices) and pre- and 14 days for non-albicans Candida. Pulmonary and blood dominantly were sustained in Afghanistan (89%). The median isolates were isolated a median of 3 and 6 days after injury, ISS at LRMC was 22, indicating high injury severity. Eight pa- respectively, whereas the remaining sources were a median 8– tients had burn injuries (median total body surface area 18%), 12 days after injury. All isolate sources had a median ISS of and 3 patients had associated inhalational injuries. There were 21–24, except intra-abdominal isolates, which had a median 26 patients with a diagnosis of MDR infection and 25 with ISS of 34. MWI. The 29 non-albicans Candida isolates included 10 C tropicalis, 7 C glabrata,6 C parapsilosis, 2 Candida dubliniensis,2 Candida lusitaniae, and 1 each of Candida kefyr and Candida pelliculosa. Isolation of non-albicans Candida spp was associated with prior Table 1. Demographic Characteristics and Injury Circumstances, Number (%) of Military Trauma Patients (N = 127) with Candida spp antifungal exposure, blood isolates, and wound isolates in the Infections and Colonization multivariate analysis (P < .01). Only 7 patients had recurrent Candida of the same species cultured ≥7 days after initial iso- Characteristic Patients lation (3 serial wound isolates, 1 blood then wound, 1 serial Male gender 126 (99) intra-abdominal, 1 wound then blood, and 1 intra-abdominal Age, median (min-max) 23 (19–45) then wound). Regarding serial isolates, 6 patients had C albicans Mechanism of injury and 1 patient had C parapsilosis. All patients with serial isolates IED blast 90 (71) had antifungal exposure between cultures with a median dura- Gunshot wound 22 (17) tion of 8 days for echinocandins, 11 for fluconazole, 5 for vor- Non-IED blast 8 (6) iconazole, and 3 for amphotericin. The patient with recurrent C Other 7 (6) parapsilosis had 10 days of echinocandin between isolates and Burn injury 8 (6) was also the only patient to have Candida spp isolated from a Total body surface area %, median (min-max) 18 (1–45) wound prior to blood. There was no increased resistance in sec- Inhalational injury 3 (2) ond isolates. ISS at LRMC, median (min-max) 22 (8–66) Wound AIS, median (min-max) 5(2–5) All-cause mortality during initial hospitalization was 7.1% in Location of initial hospitalization patients with Candida isolation compared with 1.4% in the Southern Afghanistan 73 (57) overall TIDOS population. There were 10 unique Candida iso- Eastern Afghanistan 41 (32) lates associated with the 9 deaths (Table 3). Review of clinical Iraq 7 (6) records for these patients did not identify Candida as a cause Other 6 (5) of death by autopsy or death certificate. Prior combination an- Facility at initial presentation tifungal exposure was noted in 7% of Candida isolates associat- Mobile medical unit within combat zone 26 (20) ed with survival compared with 30% of Candida isolates Hospital within combat zone 100 (79) associated with all-cause mortality (P <.05). In addition, 50% LRMC 1 (1) and 16% of isolates associated with death and survival, respec- Mortality during initial hospitalization 9 (7) tively, were from patients with gunshot wounds (P < .05). Over- Abbreviations: AIS, abbreviated injury scale; IED, improvised explosive device; all, mortality was not significantly associated with MWI, MDR, ISS, injury severity score; LRMC, Landstuhl Regional Medical Center. The number of patients with available wound AIS is 35. Candida infection, and either CLSI or AEI nonsusceptibility. Candida Relevance in Combat Casualties OFID 3 � � Table 2. Clinical Characteristics, Number (%) of Military Trauma Patients With Candida albicans Versus Non-albicans Candida Isolates a a C albicans Candida Non-albicans Univariate Analysis Multivariate Analysis Characteristic (n = 102) (n = 29) P Value P Value Age, median (min-max) 23 (19–45) 26 (19–42) .05 NA Mechanism of injury .25 NA IED blast 71 (70) 21 (72) Gunshot wound 19 (19) 5 (17) Non-IED blast 8 (8) 0 Other 4 (4) 3 (10) ISS, median (min-max) 22 (8–50) 24 (10–66) .40 NA Wound AIS, median (min-max) 4(2–5) 5 (2–5) .42 NA Location of initial hospitalization .40 NA Southern Afghanistan 54 (53) 19 (66) NA Eastern Afghanistan 38 (37) 6 (21) NA Iraq 6 (6) 2 (7) NA Other 4 (3) 2 (7) NA Mold wound infection 16 (16) 9 (31) .06 .38 Days from injury to culture, median 6(1–66) 14 (2–127) <.01 .49 (min-max) Facility where cultures were collected <.01 .92 Landstuhl Regional Medical Center 54 (53) 5 (17) United States clinical site 48 (47) 24 (83) Source of isolate Blood 9 (9) 8 (28) <.01 <.01 Wound 20 (20) 17 (59) <.01 <.01 Respiratory 59 (58) 4 (14) <.01 .33 Intra-abdominal 5 (5) 0 .59 NA Other 9 (9) 0 .21 NA Clinically diagnosed infection 52 (51) 22 (76) <.05 .10 Blood 9 (17) 7 (32) Wound 18 (35) 14 (64) Respiratory 16 (31) 1 (5) Intra-abdominal 4 (8) 0 Other 5 (10) 0 Prior antifungal exposure 9 (9) 14 (48) <.01 <.01 Any nonsusceptibility by CLSI 2 (2) 4 (14) <.05 NA Any nonsusceptibility by AEI 0 18 (62) <.01 NA Mortality during initial hospitalization 7 (7) 3 (10) .69 NA Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity score; max, maximum; min, minimum; NA, not applicable. The univariate and multivariate analyses compare the data of the C albicans isolates to the C non-albicans. The number of isolates related to wound AIS was 19 and 16 for C albicans and C non-albicans, respectively. Fifteen of 16 blood isolates were identified as blood stream infections. One isolate identified from a catheter tip culture. Infectious disease events were classified by a combination of clinical findings, laboratory tests, clinical diagnosis, and/or initiation of directed antimicrobial therapy for ≥5days [16]. Candida spp were isolated during the infection event. Susceptibility of Candida Isolates both interpretations (Table 4). Moreover, all C albicans isolates Two percent of C albicans and 14% of non-albicans Candida were susceptible to caspofungin and itraconazole by CLSI and isolates were noted to be nonsusceptible to at least 1 antifungal posaconazole by AEI. by CLSI criteria, whereas 0% and 62%, respectively, were non- Nonsusceptibility by CLSI was associated with non-albicans susceptible to 1 or more antifungals by AEI criteria. Candida Candida spp (P < .05). By AEI breakpoints, 14% of isolates were albicans isolates were universally susceptible to micafungin, ani- nonsusceptible (Table 5). In the multivariate analysis, only non- dulafungin, voriconazole, fluconazole, and amphotericin by albicans Candida sppremainedsignificantly associated with 4 OFID Blyth et al � � isolation. In addition, none of the resistant isolates by CLSI Table 3. Clinical Characteristics, Number (%) Among Patients With Candida Isolation by Outcome were treated with antifungal monotherapy to which they were not susceptible. Only 2 isolates not associated with infection Survival Death P were treated with echinocandin monotherapy for more than 1 Characteristic (n = 121) (n = 10) Value day. These were also the only echinocandin nonsusceptible iso- Age, median (min-max) 23 (19–45) 23 (21–41) .84 lates associated with death. Mechanism of injury .04 IED blast 88 (73) 4 (40) .06 DISCUSSION Gunshot wound 19 (16) 5 (50) .02 Non-IED blast 8 (7) 0 1.00 Natural disasters and manmade bombing injuries can be com- Other 6 (5) 1 (10) .43 plicated by MDR bacterial infections and MWI. Previous stud- ISS, median (min-max) 22 (8–51) 26 (14–66) .11 ies have primarily focused on mold infections related to Wound AIS, median 5(2–5) 5 (4–5) .87 (min-max) necrotizing cutaneous mucormycosis after the Joplin tornado Site of wound isolates .004 [6] and MWI complicating combat-related injuries in military Leg 12 (34) 1 (50) personnel from Afghanistan [3–5]. These studies did not specif- Arm 4 (11) 0 ically address Candida spp, despite their frequent isolation from Abdomen 2 (6) 0 these complicated wounds [3]. Our data reveal that Candida Chest/back 0 1 (50) isolation is common in combat-related injured personnel and Pelvis/groin 9 (26) 0 may be reflective of a population at higher risk for death. Al- Face/head 4 (11) 0 though C albicans isolation was not associated with resistance Other 4 (11) 0 in this population, non-albicans Candida spp were associated with Location of initial .72 hospitalization decreased susceptibility and may be linked with sources more Southern Afghanistan 67 (55) 6 (60) commonly related to infection, such as blood and wounds. Eastern Afghanistan 40 (33) 4 (40) Studies have shown that 5% of deployment-related infections Iraq 8 (7) 0 involve Candida spp [30], as well as representing the second- Other 6 (5) 0 most common organism in positive blood cultures in a popula- Mold wound infection 23 (19) 2 (20) 1.00 tion of veterans of the recent conflicts [31].A civilian population MDR bacterial infection 24 (20) 3 (30) .43 of mostly blunt trauma with complicated postoperative courses Non-albicans species 27 (22) 2 (20) .69 had rates of Candida colonization and infection of 36.6% and Source of isolate .16 6.1%, respectively [32]. The applicability to complex, penetrat- Blood 14 (12) 3 (30) ing war wounds sustained via blasts is uncertain. Microbiolog- Wound 35 (29) 2 (20) Respiratory 60 (49) 3 (30) ical studies after penetrating injuries during natural disasters Intra-abdominal 5 (4) 0 commonly isolate Candida spp, which in some cases account Other 7 (6) 2 (20) for almost one fifth of positive cultures [1, 2, 33]. These infec- Clinical evidence of infection 69 (57) 5 (50) 1.00 tions may be underrecognized because they can appear clinical- Prior antifungal exposure 20 (16) 3 (30) .38 ly similar to bacterial infections [34]. Prior combination antifungal 8 (7) 3 (30) .04 In our patient cohort, the most frequent source of Candida exposure isolation associated with infection was wounds, likely due to Any nonsusceptibility by CLSI 5 (4) 1 (10) .39 the predominance of blast injuries (77%). Wounds were also Any nonsusceptibility by AEI 16 (13) 2 (20) .41 frequently associated with non-albicans Candida spp. Although Abbreviations: AEI, adjusted-European Committee on Antimicrobial Sus- Candida spp are typically considered to be from nosocomial or ceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity colonizing sources, there is some question of traumatic inocu- score; MDR, multidrug-resistant; max, maximum; min, minimum. lation in penetrating injuries. In the MWI cohort, traumatic in- The number of isolates related to wound AIS was 35 and 3 for the survival and oculation of multiple mold species occurred, and 9% of patients mortality categories, respectively. also had C albicans isolated from wound cultures [3]. A pro- spective study of 350 patients with blast and fragment injuries after a cluster munitions explosion had a 13.2% rate of Candida AEI nonsusceptibility (Table 6). Nonsusceptibility by CLSI, andmoldinfectionsdespite weekly fluconazole prophylaxis. AEI, and discordance between CLSI and AEI interpretations The timing of Candida isolation was not included, but 10% of were not associated with death or Candida infection. patients had late cultures [9]. Another series of patients sustain- Of the 6 isolates noted to have nonsusceptibility by CLSI ing non-gastrointestinal injuries after a bomb blast in a crowded breakpoints, none were associated with mortality or serial marketplace had a 30% rate of candidemia ∼12 days after injury Candida Relevance in Combat Casualties OFID 5 � � Table 4. Candida albicans First Isolates MIC , MIC , and CLSI Versus AEI Susceptibility Interpretations to Commonly Used Antifungals 50 90 (N = 102) CLSI Interpretation AEI Interpretation Antifungal MIC (µg/mL) MIC (µg/mL) Minimum Maximum %Susceptible %Resistant %Susceptible %Resistant 50 90 Anidulafungin 0.03 0.06 ≤0.015 0.12 100 0 100 0 Micafungin ≤0.008 0.015 ≤0.008 0.015 100 0 100 0 Caspofungin 0.06 0.06 0.015 0.12 100 0 NE NE Posaconazole 0.015 0.03 ≤0.008 0.06 NE NE 100 0 Voriconazole ≤0.008 0.015 ≤0.008 0.06 100 0 100 0 Itraconazole 0.06 0.12 ≤0.015 0.12 100 0 NE NE Fluconazole 0.05 1 0.25 2 100 0 100 0 5-Flucytosine 0.12 1 <0.06 >64 98 2 NE NE Amphotericin 1 1 0.05 1 100 0 100 0 Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; CLSI, Clinical and Laboratory Standards Institute; MIC , minimum inhibitory concentration to inhibit growth of 50% of organisms; MIC , minimum inhibitory concentration to inhibit growth of 90% of organisms; NE, not established. without evidence of preceding Candida mucosal colonization. infections and colonization as patients are evacuated through Although there was a higher percentage of total-body surface echelons of care, emphasizing the importance of infection con- burn area involvement in candidemic compared with noncan- trol, judicious antimicrobial use, and continued microbiological didemic patients, a multivariate analysis found that inhalational reevaluation with changing clinical status in this severely injury was the best predictor for candidemia [8]. Other studies injured population [37]. have shown that although only fungal wound infection (includ- Wounded military personnel with Candida infection and col- ing both yeasts and molds) is associated with increased mortal- onization had a median ISS of 22 and a mortality rate of 7.1%. ity in burn patients, fungal wound colonization precedes This result is similar to the median ISS of 20 and crude mortality infection in 40% of cases [35]. Moreover, the number of sites of 7.8% seen with combat-related MWI [3, 4] and significantly colonized with Candida spp has a direct correlation with subse- higher than the 1.4% mortality within the overall TIDOS cohort quent risk for candidemia [36]. In contrast, few patients in this during our study period and the mean ISS of 7.8 from 2003 to series had Candida-associated burn injuries, and no patients 2009 [30]. Although there was no clinical evidence of mortality with Candida spp isolated from pulmonary sources had the as- due to Candida infection within this population, the high ISS and sociated inhalational injury. mortality rate reflect the severity of injuries associated with In our analysis, we found a 20% rate of MWI and MDR bac- Candida colonization and infection. This increased injury se- terial infections among patients with Candida. With environ- verity could also have led to more frequent culture obtainment mental contamination of wounds, subsequent infections are and, thus, increased Candida recovery. often polymicrobial and affected by the conditions of contam- Although some studies have shown no difference in mortality ination [1–3]. Superinfected wounds after the 2004 tsunami, in the presence of Candida colonization and infection in trauma Marmara earthquake, and Joplin tornado had high rates of patients [32], a meta-analysis showed decreased overall and at- MDR bacteria [1, 2, 7]. Whether these were associated with en- tributable mortality to Candida infections with azole prophy- vironmental sources or emergency healthcare settings is unclear laxis in intensive care unit trauma patients [38]. Nonetheless, [1]. After a tornado in Lubbock, Texas, wound infections had these studies had heterogeneous populations with high rates 4.6 species per wound in hospitalized patients. Fungal cultures of confounding risk factors and primarily blunt-trauma from these patients yielded 3 unspeciated yeasts, 1 Rhodotorula, injuries. With prior antifungal exposure associated with non- and 8 molds [33]. In the Joplin tornado cohort with Apophyso- albicans Candida isolation and its decreased antifungal suscept- myces trapeziformis-necrotizing wound infections, both pediat- ibility, and no evidence of mortality from Candida or serial iso- ric patients and more than half of incident wounds in adults lation, it is difficult to recommend antifungal prophylaxis in also had Candida spp isolated [6, 7]. Although there are data those suffering penetrating trauma. The high rate of MDR to support environmental sources of wound infection isolates, bacterial and MWI coexistence in patients with Candida delayed recovery and resistance patterns of some later isolates wound involvement may favor a strong role for surgical de- also point to the possibility of low initial inoculum, or, more bridement [1–3, 6, 7, 33]. likely, nosocomial sources. More recent studies have reflected There is concern regarding increasing resistance within Can- the ongoing evolution of microbiology related to both wound dida spp. Overall, the MIC distribution of our first isolates 6 OFID Blyth et al � � Candida Relevance in Combat Casualties OFID 7 � � Table 5. In Vitro Susceptibilities as Determined by Sensititre YeastOne Antifungal Plate by CLSI, and AEI Interpretations for Most Frequently Isolated Candida Non-albicans Species Minimum Inhibitory Concentration (µg/mL) CLSI Interpretation (%) AEI Interpretation (%) Species Antifungal ≤0.008 0.015 0.03 0.06 0.12 0.25 0.5 1 2 4 8 64 128 S SDD I R S SDD I R C tropicalis (n = 10) Anidulafungin NA 3 6 1 NA NA 90 0 10 90 10 Micafungin 1 8 1 NA NA 90 0 10 NE NE NE NE Caspofungin 4 5 1 NA NA 90 0 10 NE NE NE NE Posaconazole 1 5 3 1 NA NA NE NE NE NE 60 40 Voriconazole 5 4 1 NA NA 90 10 0 90 10 Itraconazole NA 2 6 2 NA NA 20 80 0 NE NE NE NE Fluconazole NA NA NA NA 5 3 1 1 80 10 10 80 10 10 Amphotericin NA NA NA NA 10 NA NA 100 0 100 0 C glabrata (n = 7) Anidulafungin NA 1 4 1 1 NA NA 100 0 0 100 0 Micafungin 7 NA NA 100 0 0 100 0 Caspofungin 1 5 1 NA NA 100 0 0 NE NE NE NE Posaconazole 5 2* NA NA NE NE NE NE NE NE NE NE Voriconazole 3 2 2 NA NA NE NE NE NE NE NE NE NE Itraconazole NA 5 2 NA NA 0 71 29 NE NE NE NE Fluconazole NA NA NA NA 5 1 1 71 29 0 71 29 Amphotericin NA NA NA NA 7 NA NA 100 0 100 0 C parapsilosis (n = 6) Anidulafungin NA 6 NA NA 100 0 0 0 100 0 Micafungin 4 2 NA NA 100 0 0 0 100 0 Caspofungin 6 NA NA 100 0 0 NE NE NE NE Posaconazole 2 4 NA NA NE NE NE NE 100 0 Voriconazole 4 2 NA NA 100 0 0 100 0 Itraconazole NA 1 2 3 NA NA 100 0 0 NE NE NE NE Fluconazole NA NA NA NA 1 5 100 0 0 100 0 0 Amphotericin NA NA NA NA 6 NA NA 100 0 100 0 Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; CLSI, Clinical and Laboratory Standards Institute; I, intermediate; MIC, minimum inhibitory concentration; NA, not applicable; NE, not established; R, resistant; S, susceptible; SDD, susceptible-dose dependent. *MIC >8 µg/mL. MIC ≤0.015 µg/mL. Table 6. Clinical Characteristics, Number (%) of CLSI Versus AEI Susceptible and Resistant Isolates CLSI Interpretation AEI Interpretation Nonsusceptible Susceptible Nonsusceptible Susceptible Characteristic (n =6) (n = 125) (n = 18) (n = 113) Age, median (min-max) 23 (19–32) 23 (19–45) 26 (19–42) 23 (19–45) Mechanism of Injury IED blast 5 (83) 87 (70) 13 (72) 79 (70) Gunshot wound 1 (17) 23 (18) 4 (22) 20 (18) Non-IED blast 0 8 (6) 0 8 (7) Other 0 7 (6) 1 (6) 6 (5) ISS, median (min-max) 22 (8–66) 29 (14–50) 19.5 (10–50) 24 (8–66) Wound, AIS median (min-max) 4(2–5) 5 (2–5) 4.5 (2–5) 5 (2–5) Wound site 2 (33) 35 (28) 12 (67) 25 (22) Leg 0 13 (37) 6 (50) 7 (28) Arm 0 4 (11) 1 (8) 3 (12) Abdomen 1 (50) 1 (3) 2 (16) 0 Chest/back 0 1 (3) 1 (8) 0 Pelvis/groin 0 9 (26) 1 (8) 8 (32) Face/head 1 (50) 3 (9) 1 (8) 3 (12) Other 0 4 (11) 0 4 (16) Location of initial hospitalization Southern Afghanistan 4 (67) 69 (55) 12 (67) 61 (54) Eastern Afghanistan 1 (17) 43 (34) 4 (22) 40 (35) Iraq 0 8 (6) 1 (6) 7 (6) Other 1 (17) 5 (4) 1 (6) 5 (4) †† Mold wound infection 1 (17) 24 (19) 7 (39) 18 (16) † † †† Non-albicans species 4 (67) 25 (20) 18 (100) 11 (10) * Source of isolate †† Blood 2 (33) 15 (12) 5 (28) 12 (11) †† Wound 2 (33) 35 (28) 12 (67) 25 (22) †† Respiratory 2 (33) 61 (49) 1 (6) 62 (55) Intra-abdominal 0 5 (4) 0 5 (4) Other 0 9 (7) 0 9 (8) Clinically diagnosed infection 4 (67) 70 (56) 14 (78) 60 (53) †† Prior antifungal exposure 2 (33) 17 (14) 8 (44) 15 (13) Death 1 (17) 8 (6) 2 (11) 8 (7) Days from culture to death, median (min-max) 10 (10–10) 4.5 (0–71) 17 (17–17) 4.5 (0–71) Days from injury to death, median (min-max) 19 (19–19) 14.5 (1–76) 36 (29–43) 14.5 (1–76) Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity score; max, maximum; min, minimum; MWI, mold wound infection. P value <.05 in univariate analysis. †† P value <.01 in univariate analysis. * P value <.05 in multivariate analysis for AEI only (included MWI Y/N, Non-albicans Y/N, antifungal before, source of isolate including blood, wound, and respiratory). The number of isolates related to wound AIS was 2 and 33 for the CLSI nonsusceptible and susceptible, respectively, and 12 and 23 for AEI nonsusceptible and susceptible, respectively. The number of isolates related to days from culture/injury to death was 1 and 8 for the CLSI interpretations of nonsusceptible and susceptible, respectively, and 2 and 8 for the AEI interpretations. matches published epidemiological cutoff values [10]. Candida resistant C albicans isolates, few serial isolates with prolonged, albicans isolates were highly susceptible by both CLSI and AEI targeted antifungals, or increased non-albicans Candida spp re- criteria. We did not find that antifungal exposure was associated covered after antifungal exposure. Antifungal exposure was asso- with C albicans resistance. This may be related to our lack of ciated with nonsusceptibility within non-albicans Candida spp. 8 OFID Blyth et al � � Although prior studies have shown a direct relationship be- References tween infection-related mortality and rising antifungal MICs 1. Maegele M, Gregor S, Steinhausen E, et al. The long-distance tertiary air [10, 15, 39, 40], we did not find an association between antifun- transfer and care of tsunami victims: injury pattern and microbiological and psychological aspects. Crit Care Med 2005; 33:1136–40. gal nonsusceptibility and serial isolation, infection, or death. In 2. Kazancioglu R, Cagatay A, Calangu S, et al. The characteristics of infec- our population, very few patients with infection were treated tions in crush syndrome. Clin Microbiol Infect 2002; 8:202–6. with antifungal monotherapy to which the isolate was nonsus- 3. Warkentien T, Rodriguez C, Lloyd B, et al. Invasive mold infections fol- ceptible. These patients did not fare worse; however, there are lowing combat-related injuries. Clin Infect Dis 2012; 55:1441–9. 4. Weintrob AC, Weisbrod AB, Dunne JR, et al. Combat trauma-associated multiple limitations of this study that could affect our ability invasive fungal wound infections: epidemiology and clinical classifica- to detect a difference. These include the small number of non- tion. Epidemiol Infect [in press]. doi: 10.1017/S095026881400051X. susceptible isolates [39] and application of established criteria 5. Rodriguez CJ, Weintrob AC, Shah J, et al. Risk factors associated with invasive fungal infections in combat trauma. Surg Infect (Larchmt) defining pneumonia [16] used in the TIDOS project, which 2014; 15:521–6. do not require histopathology to more specifically attribute 6. Neblett Fanfair R, Benedict K, Bos J, et al. Necrotizing cutaneous mu- Candida isolates from respiratory specimens to actual infection. cormycosis after a tornado in Joplin, Missouri, in 2011. N Engl J Med 2012; 367:2214–25. This predefined criteria led to identifying 17 of 63 pulmonary 7. Weddle G, Gandy K, Bratcher D, et al. Apophysomyces trapeziformis in- isolates as associated with infection. In general, these findings fection associated with a tornado-related injury. Pediatr Infect Dis J support continued correlation of AST with clinical outcomes. 2012; 31:640–2. Overall, our data from combat-related injured military 8. Wolf DG, Polacheck I, Block C, et al. High rate of candidemia in pa- tients sustaining injuries in a bomb blast at a marketplace: a possible personnel support prior clinical and microbiologic studies of environmental source. Clin Infect Dis 2000; 31:712–6. fungal traumatic inoculations. In this population, Candida 9. Fares Y, El-Zaatari M, Fares J, et al. Trauma-related infections due to isolation is common and may be reflective of a population at cluster munitions. J Infect Public Health 2013; 6:482–6. 10. Pfaller MA, Andes D, Diekema DJ, et al. Wild-type MIC distributions, higher risk for infections with MDR bacteria, MWI, and death. epidemiological cutoff values and species-specific clinical breakpoints There was little resistance in Candida isolates. Nonetheless, for fluconazole and Candida: time for harmonization of CLSI and EU- non-albicans Candida spp were more likely to be isolated from CAST broth microdilution methods. Drug Resist Updat 2010;13:180–95. 11. Clinical and Laboratory Standards Institute. Reference Method for clinically significant sites such as blood and wounds. These iso- Broth Dilution Antifungal Susceptibility Testing of Yeasts; Fourth In- lates were associated with prior antifungal therapy and, of most formational Supplement. CLSI document M27-S4. Clinical and Labora- immediate clinical concern, decreased susceptibility to antifun- tory Standards Institute, Wayne, PA; 2012. gals. Without greater numbers of resistant Candida isolates as- 12. Subcommittee on Antifungal Susceptibility Testing (AFST) of the ESC- MID European Committee for Antimicrobial Susceptibility Testing sociated with infection, the significance of targeted antifungal (EUCAST). EUCAST definitive document EDef 7.1: method for the de- therapy and/or surgical interventions remains unclear. Further termination of broth dilution MICs of antifungal agents for fermenta- studies focusing on isolates associated with infection, including tive yeasts. Clin Microbiol Infect 2008; 14:398–405. 13. Arendrup MC, Cuenca-Estrella M, Lass-Florl C, et al. EUCAST techni- more resistant isolates, are needed to determine the clinical sig- cal note on the EUCAST definitive document EDef 7.2: method for the nificance and appropriate management of these infections. determination of broth dilution minimum inhibitory concentrations of antifungal agents for yeasts EDef 7.2 (EUCAST-AFST). Clin Microbiol Infect 2012; 18:E246–7. Acknowledgments 14. Pfaller MA, Chaturvedi V, Diekema DJ, et al. Clinical evaluation of the We are indebted to the Infectious Disease Clinical Research Program Sensititre YeastOne colorimetric antifungal panel for antifungal sus- TIDOS study team of clinical coordinators, microbiology technicians, data ceptibility testing of the echinocandins anidulafungin, caspofungin, managers, clinical site managers, and administrative support personnel for and micafungin. J Clin Microbiol 2008; 46:2155–9. their tireless hours to ensure the success of this project. 15. van Hal SJ, Chen SC, Sorrell TC, et al. Support for the EUCAST and Disclaimer. The views expressed are those of the authors and does not revised CLSI fluconazole clinical breakpoints by Sensititre(R) necessarily reflect the official views of the Uniformed Services University of YeastOne(R) for Candida albicans: a prospective observational cohort the Health Sciences, the Henry M. Jackson Foundation for the Advancement study. J Antimicrob Chemother 2014; 69:2210–4. of Military Medicine, Inc., National Institute of Health or the Department of 16. Tribble DR, Conger NG, Fraser S, et al. Infection-associated clinical out- Health and Human Services, the Department of Defense or the Departments comes in hospitalized medical evacuees after traumatic injury: Trauma of the Army, Navy or Air Force. Mention of trade names, commercial prod- Infectious Disease Outcome Study. J Trauma 2011; 71:S33–42. ucts, or organization does not imply endorsement by the U.S. Government. 17. De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive Financial support. This work (the Trauma Infectious Disease Out- fungal disease from the European Organization for Research and Treat- comes Study; IDCRP-024) was supported by the Infectious Disease Clinical ment of Cancer/Invasive Fungal Infections Cooperative Group and the Research Program, a Department of Defense program executed through the National Institute of Allergy and Infectious Diseases Mycoses Study Uniformed Services University of the Health Sciences. This project was been Group (EORTC/MSG) Consensus Group. Clin Infect Dis 2008; 46: funded by the National Institute of Allergy and Infectious Diseases, National 1813–21. Institute of Health (Inter-Agency Agreement Y1-AI-5072) and the Depart- 18. Copes WS, Champion HR, Sacco WJ, et al. The Injury Severity Score ment of the Navy under the Wounded, Ill, and Injured Program (HU001- revisited. J Trauma 1988; 28:69–77. 10-1-0014). 19. Gennarelli TA, Wodzin E. AIS 2005: a contemporary injury scale. Injury Potential conflicts of interest. All authors: No reported conflicts. 2006; 37:1083–91. All authors have submitted the ICMJE Form for Disclosure of Potential 20. Champion HR, Holcomb JB, Lawnick MM, et al. Improved character- Conflicts of Interest. ization of combat injury. J Trauma 2010; 68:1139–50. Candida Relevance in Combat Casualties OFID 9 � � 21. Pfaller MA, Chaturvedi V, Diekema DJ, et al. Comparison of the Sensi- European Committee on Antibiotic Susceptibility Testing (EUCAST) and titre YeastOne colorimetric antifungal panel with CLSI microdilution four commercial techniques. Clin Microbiol Infect 2005; 11:486–92. for antifungal susceptibility testing of the echinocandins against 29. European Committee on Antimicrobial Susceptibility Testing. Rationale Candida spp., using new clinical breakpoints and epidemiological cutoff documents on antifungal agents. Available at: http://www.eucast.org/ values. Diagn Microbiol Infect Dis 2012; 73:365–8. antifungal_susceptibility_testing_afst/rationale_documents_for_ 22. Cuenca-Estrella M, Gomez-Lopez A, Alastruey-Izquierdo A, et al. Com- antifungals/. Accessed 1 June 2014. parison of the Vitek 2 antifungal susceptibility system with the clinical 30. Murray CK, Wilkins K, Molter NC, et al. Infections complicating the and laboratory standards institute (CLSI) and European Committee on care of combat casualties during Operations Iraqi Freedom and Endur- Antimicrobial Susceptibility Testing (EUCAST) Broth Microdilution ing Freedom. J Trauma 2011; 71:S62–73. Reference Methods and with the Sensititre YeastOne and Etest tech- 31. Dau B, Oda G, Holodniy M. Infectious complications in OIF/OEF niques for in vitro detection of antifungal resistance in yeast isolates. J veterans with traumatic brain injury. J Rehabil Res Dev 2009;46: Clin Microbiol 2010; 48:1782–6. 673–84. 23. Alexander BD, Byrne TC, Smith KL, et al. Comparative evaluation of 32. Manolakaki D, Velmahos G, Kourkoumpetis T, et al. Candida infection Etest and sensititre yeastone panels against the Clinical and Laboratory and colonization among trauma patients. Virulence 2010; 1:367–75. Standards Institute M27-A2 reference broth microdilution method for 33. Gilbert DN, Sanford JP, Kutscher E, et al. Microbiologic study of wound testing Candida susceptibility to seven antifungal agents. J Clin Micro- infections in tornado casualties. Arch Environ Health 1973; 26:125–30. biol 2007; 45:698–706. 34. Benedict K, Park BJ. Invasive fungal infections after natural disasters. 24. Clinical and Laboratory Standards Institute. Reference Method for Emerg Infect Dis 2014; 20:349–55. Broth Dilution Antifungal Susceptibility Testing of Yeasts: Third Infor- 35. Horvath EE, Murray CK, Vaughan GM, et al. Fungal wound infection mational Supplement. CLSI document M27-S3. Clinical and Laboratory (not colonization) is independently associated with mortality in burn Standards Institute, Wayne, PA; 2008. patients. Ann Surg 2007; 245:978–85. 25. Clinical and Laboratory Standards Institute. Reference Method for 36. Moore EC, Padiglione AA, Wasiak J, et al. Candida in burns: risk factor Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved and outcomes. J Burn Care Res 2010; 31:257–63. Standard. CLSI document M27-A3. Clinical and Laboratory Standards 37. Mende K, Beckius ML, Zera WC, et al. Phenotypic and genotypic Institute, Wayne, PA; 2008. changes over time and across facilities of serial colonizing and infecting 26. European Committee on Antimicrobial Susceptibility Testing. Antifungal Escherichia coli isolate recovered from injured service members. J Clin agents. Breakpoint tables for interpretation of MICs (v 6.1). Available at: Microbiol 2014; 52:3869–77. http://www.eucast.org/clinical_breakpoints. Accessed 1 June 2014. 38. Cruciani M, de Lalla F, Mengoli C. Prophylaxis of Candida infections in 27. Arendrup MC, Cuenca-Estrella M, Lass-Florl C, Hope WW. Break- adult trauma and surgical intensive care patients: a systematic review points for antifungal agents: an update from EUCAST focussing on and meta-analysis. Intensive Care Med 2005; 31:1479–87. echinocandins against Candida spp. and triazoles against Aspergillus 39. Rex JH, Pfaller MA. Has antifungal susceptibility testing come of age? spp. Drug Resist Updat 2013; 16:81–95. Clin Infect Dis 2002; 35:982–9. 28. Cuenca-Estrella M, Gomez-Lopez A, Mellado E, et al. Correlation between 40. Pfaller MA. Antifungal drug resistance: mechanisms, epidemiology, and the procedure for antifungal susceptibility testing for Candida spp. of the consequences for treatment. Am J Med 2012; 125:S3–13. 10 OFID Blyth et al � � http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Resistance Patterns and Clinical Significance of Candida Colonization and Infection in Combat-Related Injured Patients From Iraq and Afghanistan

Download PDF
10 pages

Loading next page...
 
/lp/oxford-university-press/resistance-patterns-and-clinical-significance-of-candida-colonization-HfxO4DqPne

References (42)

Publisher
Oxford University Press
Copyright
© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.
eISSN
2328-8957
DOI
10.1093/ofid/ofu109
pmid
25734177
Publisher site
See Article on Publisher Site

Abstract

MA JO R A R T IC LE Resistance Patterns and Clinical Significance of Candida Colonization and Infection in Combat- Related Injured Patients From Iraq and Afghanistan 1 1,2,3 2,3,4 1 1,2,3 1,2,3 Dana M. Blyth, Katrin Mende, Amy C. Weintrob, Miriam L. Beckius, Wendy C. Zera, William Bradley, 2,3 2 1 Dan Lu, David R. Tribble, and Clinton K. Murray ; the Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group 1 2 Infectious Disease Service, San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas; Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., and Infectious Disease, Walter Reed National Military Medical Center, Bethesda, Maryland Background. Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and out- comes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. Methods. Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009–October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Suscep- tibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Stan- dards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. Results. The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albi- cans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghan- istan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. Conclusions. Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate. Keywords. antifungal resistance; Candida; combat-related trauma. Introduction Received 10 October 2014; accepted 12 November 2014. Correspondence: Clinton K. Murray, MD, Chief, Infectious Disease Service, Natural disasters and manmade bombings have been Department of the Army, San Antonio Military Medical Center, MCHE-MDI, 3551 Roger Brooke Drive, JBSA-Fort Sam Houston, TX 78234-6200 (clinton.k.murray. associated with both multidrug-resistant (MDR) bacte- mil@mail.mil). rial infections and invasive mold wound infections Open Forum Infectious Diseases (MWIs) [1–7]. The risk factors and role of Candida spp © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Societyof America. This is an Open Access article distributed under the terms colonization and infection in these patients with penetrat- of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http:// ing trauma (eg, open wound contaminated by environ- creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work mental and/or organic debris) is unclear. Prior studies is not altered or transformed in any way, and that the work is properly cited. For have shown high rates of candidemia after a bomb ex- commercial re-use, please contact journals.permissions@oup.com. DOI: 10.1093/ofid/ofu109 plosion in a market [8] and Candida wound infections Candida Relevance in Combat Casualties OFID 1 � � complicating cluster bomb injuries [9]. Among trauma patients Combat-related injuries were characterized using both Injury with penetrating injuries related to natural disasters, rates of Severity Score (ISS) [18] and Abbreviated Injury Scale 2005- wound infections with Candida may be as high as 20% [1]. Military (AIS) [19, 20]. Wound AIS was defined as the AIS In recent years, there has also been a move towards harmo- score for the area of a wound or intra-abdominal culture. nizing Clinical Laboratory and Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing Candida Species Isolate Analysis (EUCAST) antifungal susceptibility testing (AST) [10]; howev- As part of TIDOS, after identification and susceptibility testing er, differences in procedures and interpretative breakpoints re- per standard procedures at clinical sites, bacterial and yeast iso- main [11–13]. Commercial AST is increasingly used in clinical lates are archived for future study at −80°C. We used all initial laboratories, and performance has been variably studied against unique and serial (≥7 days between same species) Candida iso- the new CLSI and EUCAST breakpoints [14, 15]. There are also lates. Archived isolates were passaged twice on sabouraud dex- increasing concerns regarding changes in Candida spp distribu- trose agar before further testing. The BD Phoenix Automated tions, resistance, and correlation of breakpoints with clinical Microbiology System (BD Diagnostics, Sparks, MD) was used outcomes. to confirm or determine Candida species as necessary. Sensititre In this study, we sought to identify clinical characteristics and YeastOne (YO-9) (TREK Diagnostic Systems, Cleveland, OH) outcomes associated with Candida spp colonization and infec- plates were used for broth microdilution susceptibility testing tion in deployment-related injured personnel in Iraq and [14, 21–23]. Antifungal agents analyzed included anidulafungin, Afghanistan. We also examined Candida spp distributions micafungin, caspofungin, 5-flucytosine, posaconazole, vorico- and resistance patterns according to CLSI and EUCAST nazole, itraconazole, fluconazole, and amphotericin B. breakpoints. For CLSI interpretations, AST for Candida albicans, Candida glabrata, Candida tropicalis, Candida krusei, and Candida para- psilosis were interpreted according to M27-S4 breakpoints [11]. METHODS Candida spp breakpoints not specifically addressed in M27-S4 Study Population and Definitions were determined according to M27-S3 breakpoints [24]. Am- The Trauma Infectious Disease Outcomes Study (TIDOS) was photericin susceptibility was determined by M27-A3 break- implemented on June 1, 2009. All patients with isolation of points [25]. The EUCAST breakpoints were determined by Candida spp from initiation of TIDOS to October 26, 2013 EUCAST Antifungal Agents Breakpoint Tables for Interpreta- were included in the analysis. The TIDOS eligibility criteria tion of Minimal Inhibitory Concentrations (MIC), version 6.1 have previously been described and include active duty person- [26]. nel or Department of Defense beneficiaries ≥18 years who are Although EUCAST methods to determine MIC results are injured during deployment requiring evacuation to Landstuhl intended to yield results that are concordant with CLSI proce- Regional Medical Center (LRMC) in Germany and ultimately dures, [12] differences in methodology between AST procedures transferring to a participating clinical site in the United States yield lower breakpoints for anidulafungin and micafungin by [16]. Trauma history, clinical characteristics on admission, EUCAST compared with CLSI [27]. Sensititre YeastOne may course, and outcomes were obtained retrospectively from the also yield higher MICs for select antifungals than the EUCAST TIDOS database. The study was approved by the Infectious Dis- method [28], so our MIC results were normalized against the ease Institutional Review Board of the Uniformed Services Uni- modal MIC and ranges provided by EUCAST rationale docu- versity of the Health Sciences in Bethesda, Maryland. ments [27]. The modal MIC and MIC ranges obtained by the Infectious disease events were classified, as previously de- Sensititre YeastOne were consistent with those obtained by scribed, by a combination of clinical findings, laboratory tests, EUCAST methods for all antifungals tested except anidulafun- clinical diagnosis, and/or initiation of directed antimicrobial gin and posaconazole [29], which were adjusted as appropriate therapy for ≥5days[16]. Cultures were performed at the discre- with breakpoints established 2 dilutions above the respective tion of clinical providers. Isolates associated with infections modal MICs. These modifications yielded the adjusted-EUCAST were collected as part of clinical infection work-ups, whereas interpretations (AEIs). isolates were considered to be colonizers if they were specimens obtained for purposes other than infection work-up (eg, surveil- Statistical Analysis lance). Susceptibility testing was performed by each hospital’s Univariate analysis included χ and Fisher’s exact test for cate- microbiology laboratory and interpreted by CLSI criteria. The gorical variables, as appropriate, and Mann-Whitney U for con- TIDOS database was queried for information on concomitant tinuous variables. A P value of <.05 was used as a significant bacterial and MWI within the cohort. Infections, presence of cutoff. Multivariate analysis was completed with logistic regres- MDR bacteria, and MWI are defined systematically within the sion of pertinent significant risk factors from univariate analy- TIDOS database [3, 5, 16, 17]. sis. Antifungal susceptibility by CLSI and EUCAST were not 2 OFID Blyth et al � � included in multivariate analysis because they were correlated Clinical Findings and Outcomes by Candida Isolates with non-albicans Candida species. Statistical analyses were Of the 127 patients, there were 131 unique Candida isolates. performed using SPSS software (IBM SPSS Statistics Version Onehundred twouniqueisolateswere Calbicans and 29 19, Chicago, IL). were non-albicans Candida spp (Table 2). Seventy-four isolates were associated with infection and 57 were colonizers. The majority of both Calbicans and non-albicans Candida spp RESULTS were collected from personnel injured in Afghanistan (90% and 86%, respectively). Furthermore, the majority of isolates Overall Demographics and Injury Patterns were collected at institutions within the United States (55%) During this time period, 5694 trauma patient evacuations compared with 45% at LRMC. occurred through LRMC, and 2567 patients were transferred Five candidemic patients had prior antifungal exposure with to TIDOS-participating clinical facilities in the United States. a median of 3 days preceding isolation of Candida spp. Thirty- Of these patients, 127 (5%) had Candida species for study one percent of non-albicans Candida isolates and 16% of C al- inclusion. The median age of the patients was 23 years and bicans isolates were from patients who also had MWI. Median 99% were male (Table 1). The majority of injuries were due time from injury to Candida isolation was 6 days for C albicans to blasts (71% related to improvised explosive devices) and pre- and 14 days for non-albicans Candida. Pulmonary and blood dominantly were sustained in Afghanistan (89%). The median isolates were isolated a median of 3 and 6 days after injury, ISS at LRMC was 22, indicating high injury severity. Eight pa- respectively, whereas the remaining sources were a median 8– tients had burn injuries (median total body surface area 18%), 12 days after injury. All isolate sources had a median ISS of and 3 patients had associated inhalational injuries. There were 21–24, except intra-abdominal isolates, which had a median 26 patients with a diagnosis of MDR infection and 25 with ISS of 34. MWI. The 29 non-albicans Candida isolates included 10 C tropicalis, 7 C glabrata,6 C parapsilosis, 2 Candida dubliniensis,2 Candida lusitaniae, and 1 each of Candida kefyr and Candida pelliculosa. Isolation of non-albicans Candida spp was associated with prior Table 1. Demographic Characteristics and Injury Circumstances, Number (%) of Military Trauma Patients (N = 127) with Candida spp antifungal exposure, blood isolates, and wound isolates in the Infections and Colonization multivariate analysis (P < .01). Only 7 patients had recurrent Candida of the same species cultured ≥7 days after initial iso- Characteristic Patients lation (3 serial wound isolates, 1 blood then wound, 1 serial Male gender 126 (99) intra-abdominal, 1 wound then blood, and 1 intra-abdominal Age, median (min-max) 23 (19–45) then wound). Regarding serial isolates, 6 patients had C albicans Mechanism of injury and 1 patient had C parapsilosis. All patients with serial isolates IED blast 90 (71) had antifungal exposure between cultures with a median dura- Gunshot wound 22 (17) tion of 8 days for echinocandins, 11 for fluconazole, 5 for vor- Non-IED blast 8 (6) iconazole, and 3 for amphotericin. The patient with recurrent C Other 7 (6) parapsilosis had 10 days of echinocandin between isolates and Burn injury 8 (6) was also the only patient to have Candida spp isolated from a Total body surface area %, median (min-max) 18 (1–45) wound prior to blood. There was no increased resistance in sec- Inhalational injury 3 (2) ond isolates. ISS at LRMC, median (min-max) 22 (8–66) Wound AIS, median (min-max) 5(2–5) All-cause mortality during initial hospitalization was 7.1% in Location of initial hospitalization patients with Candida isolation compared with 1.4% in the Southern Afghanistan 73 (57) overall TIDOS population. There were 10 unique Candida iso- Eastern Afghanistan 41 (32) lates associated with the 9 deaths (Table 3). Review of clinical Iraq 7 (6) records for these patients did not identify Candida as a cause Other 6 (5) of death by autopsy or death certificate. Prior combination an- Facility at initial presentation tifungal exposure was noted in 7% of Candida isolates associat- Mobile medical unit within combat zone 26 (20) ed with survival compared with 30% of Candida isolates Hospital within combat zone 100 (79) associated with all-cause mortality (P <.05). In addition, 50% LRMC 1 (1) and 16% of isolates associated with death and survival, respec- Mortality during initial hospitalization 9 (7) tively, were from patients with gunshot wounds (P < .05). Over- Abbreviations: AIS, abbreviated injury scale; IED, improvised explosive device; all, mortality was not significantly associated with MWI, MDR, ISS, injury severity score; LRMC, Landstuhl Regional Medical Center. The number of patients with available wound AIS is 35. Candida infection, and either CLSI or AEI nonsusceptibility. Candida Relevance in Combat Casualties OFID 3 � � Table 2. Clinical Characteristics, Number (%) of Military Trauma Patients With Candida albicans Versus Non-albicans Candida Isolates a a C albicans Candida Non-albicans Univariate Analysis Multivariate Analysis Characteristic (n = 102) (n = 29) P Value P Value Age, median (min-max) 23 (19–45) 26 (19–42) .05 NA Mechanism of injury .25 NA IED blast 71 (70) 21 (72) Gunshot wound 19 (19) 5 (17) Non-IED blast 8 (8) 0 Other 4 (4) 3 (10) ISS, median (min-max) 22 (8–50) 24 (10–66) .40 NA Wound AIS, median (min-max) 4(2–5) 5 (2–5) .42 NA Location of initial hospitalization .40 NA Southern Afghanistan 54 (53) 19 (66) NA Eastern Afghanistan 38 (37) 6 (21) NA Iraq 6 (6) 2 (7) NA Other 4 (3) 2 (7) NA Mold wound infection 16 (16) 9 (31) .06 .38 Days from injury to culture, median 6(1–66) 14 (2–127) <.01 .49 (min-max) Facility where cultures were collected <.01 .92 Landstuhl Regional Medical Center 54 (53) 5 (17) United States clinical site 48 (47) 24 (83) Source of isolate Blood 9 (9) 8 (28) <.01 <.01 Wound 20 (20) 17 (59) <.01 <.01 Respiratory 59 (58) 4 (14) <.01 .33 Intra-abdominal 5 (5) 0 .59 NA Other 9 (9) 0 .21 NA Clinically diagnosed infection 52 (51) 22 (76) <.05 .10 Blood 9 (17) 7 (32) Wound 18 (35) 14 (64) Respiratory 16 (31) 1 (5) Intra-abdominal 4 (8) 0 Other 5 (10) 0 Prior antifungal exposure 9 (9) 14 (48) <.01 <.01 Any nonsusceptibility by CLSI 2 (2) 4 (14) <.05 NA Any nonsusceptibility by AEI 0 18 (62) <.01 NA Mortality during initial hospitalization 7 (7) 3 (10) .69 NA Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity score; max, maximum; min, minimum; NA, not applicable. The univariate and multivariate analyses compare the data of the C albicans isolates to the C non-albicans. The number of isolates related to wound AIS was 19 and 16 for C albicans and C non-albicans, respectively. Fifteen of 16 blood isolates were identified as blood stream infections. One isolate identified from a catheter tip culture. Infectious disease events were classified by a combination of clinical findings, laboratory tests, clinical diagnosis, and/or initiation of directed antimicrobial therapy for ≥5days [16]. Candida spp were isolated during the infection event. Susceptibility of Candida Isolates both interpretations (Table 4). Moreover, all C albicans isolates Two percent of C albicans and 14% of non-albicans Candida were susceptible to caspofungin and itraconazole by CLSI and isolates were noted to be nonsusceptible to at least 1 antifungal posaconazole by AEI. by CLSI criteria, whereas 0% and 62%, respectively, were non- Nonsusceptibility by CLSI was associated with non-albicans susceptible to 1 or more antifungals by AEI criteria. Candida Candida spp (P < .05). By AEI breakpoints, 14% of isolates were albicans isolates were universally susceptible to micafungin, ani- nonsusceptible (Table 5). In the multivariate analysis, only non- dulafungin, voriconazole, fluconazole, and amphotericin by albicans Candida sppremainedsignificantly associated with 4 OFID Blyth et al � � isolation. In addition, none of the resistant isolates by CLSI Table 3. Clinical Characteristics, Number (%) Among Patients With Candida Isolation by Outcome were treated with antifungal monotherapy to which they were not susceptible. Only 2 isolates not associated with infection Survival Death P were treated with echinocandin monotherapy for more than 1 Characteristic (n = 121) (n = 10) Value day. These were also the only echinocandin nonsusceptible iso- Age, median (min-max) 23 (19–45) 23 (21–41) .84 lates associated with death. Mechanism of injury .04 IED blast 88 (73) 4 (40) .06 DISCUSSION Gunshot wound 19 (16) 5 (50) .02 Non-IED blast 8 (7) 0 1.00 Natural disasters and manmade bombing injuries can be com- Other 6 (5) 1 (10) .43 plicated by MDR bacterial infections and MWI. Previous stud- ISS, median (min-max) 22 (8–51) 26 (14–66) .11 ies have primarily focused on mold infections related to Wound AIS, median 5(2–5) 5 (4–5) .87 (min-max) necrotizing cutaneous mucormycosis after the Joplin tornado Site of wound isolates .004 [6] and MWI complicating combat-related injuries in military Leg 12 (34) 1 (50) personnel from Afghanistan [3–5]. These studies did not specif- Arm 4 (11) 0 ically address Candida spp, despite their frequent isolation from Abdomen 2 (6) 0 these complicated wounds [3]. Our data reveal that Candida Chest/back 0 1 (50) isolation is common in combat-related injured personnel and Pelvis/groin 9 (26) 0 may be reflective of a population at higher risk for death. Al- Face/head 4 (11) 0 though C albicans isolation was not associated with resistance Other 4 (11) 0 in this population, non-albicans Candida spp were associated with Location of initial .72 hospitalization decreased susceptibility and may be linked with sources more Southern Afghanistan 67 (55) 6 (60) commonly related to infection, such as blood and wounds. Eastern Afghanistan 40 (33) 4 (40) Studies have shown that 5% of deployment-related infections Iraq 8 (7) 0 involve Candida spp [30], as well as representing the second- Other 6 (5) 0 most common organism in positive blood cultures in a popula- Mold wound infection 23 (19) 2 (20) 1.00 tion of veterans of the recent conflicts [31].A civilian population MDR bacterial infection 24 (20) 3 (30) .43 of mostly blunt trauma with complicated postoperative courses Non-albicans species 27 (22) 2 (20) .69 had rates of Candida colonization and infection of 36.6% and Source of isolate .16 6.1%, respectively [32]. The applicability to complex, penetrat- Blood 14 (12) 3 (30) ing war wounds sustained via blasts is uncertain. Microbiolog- Wound 35 (29) 2 (20) Respiratory 60 (49) 3 (30) ical studies after penetrating injuries during natural disasters Intra-abdominal 5 (4) 0 commonly isolate Candida spp, which in some cases account Other 7 (6) 2 (20) for almost one fifth of positive cultures [1, 2, 33]. These infec- Clinical evidence of infection 69 (57) 5 (50) 1.00 tions may be underrecognized because they can appear clinical- Prior antifungal exposure 20 (16) 3 (30) .38 ly similar to bacterial infections [34]. Prior combination antifungal 8 (7) 3 (30) .04 In our patient cohort, the most frequent source of Candida exposure isolation associated with infection was wounds, likely due to Any nonsusceptibility by CLSI 5 (4) 1 (10) .39 the predominance of blast injuries (77%). Wounds were also Any nonsusceptibility by AEI 16 (13) 2 (20) .41 frequently associated with non-albicans Candida spp. Although Abbreviations: AEI, adjusted-European Committee on Antimicrobial Sus- Candida spp are typically considered to be from nosocomial or ceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity colonizing sources, there is some question of traumatic inocu- score; MDR, multidrug-resistant; max, maximum; min, minimum. lation in penetrating injuries. In the MWI cohort, traumatic in- The number of isolates related to wound AIS was 35 and 3 for the survival and oculation of multiple mold species occurred, and 9% of patients mortality categories, respectively. also had C albicans isolated from wound cultures [3]. A pro- spective study of 350 patients with blast and fragment injuries after a cluster munitions explosion had a 13.2% rate of Candida AEI nonsusceptibility (Table 6). Nonsusceptibility by CLSI, andmoldinfectionsdespite weekly fluconazole prophylaxis. AEI, and discordance between CLSI and AEI interpretations The timing of Candida isolation was not included, but 10% of were not associated with death or Candida infection. patients had late cultures [9]. Another series of patients sustain- Of the 6 isolates noted to have nonsusceptibility by CLSI ing non-gastrointestinal injuries after a bomb blast in a crowded breakpoints, none were associated with mortality or serial marketplace had a 30% rate of candidemia ∼12 days after injury Candida Relevance in Combat Casualties OFID 5 � � Table 4. Candida albicans First Isolates MIC , MIC , and CLSI Versus AEI Susceptibility Interpretations to Commonly Used Antifungals 50 90 (N = 102) CLSI Interpretation AEI Interpretation Antifungal MIC (µg/mL) MIC (µg/mL) Minimum Maximum %Susceptible %Resistant %Susceptible %Resistant 50 90 Anidulafungin 0.03 0.06 ≤0.015 0.12 100 0 100 0 Micafungin ≤0.008 0.015 ≤0.008 0.015 100 0 100 0 Caspofungin 0.06 0.06 0.015 0.12 100 0 NE NE Posaconazole 0.015 0.03 ≤0.008 0.06 NE NE 100 0 Voriconazole ≤0.008 0.015 ≤0.008 0.06 100 0 100 0 Itraconazole 0.06 0.12 ≤0.015 0.12 100 0 NE NE Fluconazole 0.05 1 0.25 2 100 0 100 0 5-Flucytosine 0.12 1 <0.06 >64 98 2 NE NE Amphotericin 1 1 0.05 1 100 0 100 0 Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; CLSI, Clinical and Laboratory Standards Institute; MIC , minimum inhibitory concentration to inhibit growth of 50% of organisms; MIC , minimum inhibitory concentration to inhibit growth of 90% of organisms; NE, not established. without evidence of preceding Candida mucosal colonization. infections and colonization as patients are evacuated through Although there was a higher percentage of total-body surface echelons of care, emphasizing the importance of infection con- burn area involvement in candidemic compared with noncan- trol, judicious antimicrobial use, and continued microbiological didemic patients, a multivariate analysis found that inhalational reevaluation with changing clinical status in this severely injury was the best predictor for candidemia [8]. Other studies injured population [37]. have shown that although only fungal wound infection (includ- Wounded military personnel with Candida infection and col- ing both yeasts and molds) is associated with increased mortal- onization had a median ISS of 22 and a mortality rate of 7.1%. ity in burn patients, fungal wound colonization precedes This result is similar to the median ISS of 20 and crude mortality infection in 40% of cases [35]. Moreover, the number of sites of 7.8% seen with combat-related MWI [3, 4] and significantly colonized with Candida spp has a direct correlation with subse- higher than the 1.4% mortality within the overall TIDOS cohort quent risk for candidemia [36]. In contrast, few patients in this during our study period and the mean ISS of 7.8 from 2003 to series had Candida-associated burn injuries, and no patients 2009 [30]. Although there was no clinical evidence of mortality with Candida spp isolated from pulmonary sources had the as- due to Candida infection within this population, the high ISS and sociated inhalational injury. mortality rate reflect the severity of injuries associated with In our analysis, we found a 20% rate of MWI and MDR bac- Candida colonization and infection. This increased injury se- terial infections among patients with Candida. With environ- verity could also have led to more frequent culture obtainment mental contamination of wounds, subsequent infections are and, thus, increased Candida recovery. often polymicrobial and affected by the conditions of contam- Although some studies have shown no difference in mortality ination [1–3]. Superinfected wounds after the 2004 tsunami, in the presence of Candida colonization and infection in trauma Marmara earthquake, and Joplin tornado had high rates of patients [32], a meta-analysis showed decreased overall and at- MDR bacteria [1, 2, 7]. Whether these were associated with en- tributable mortality to Candida infections with azole prophy- vironmental sources or emergency healthcare settings is unclear laxis in intensive care unit trauma patients [38]. Nonetheless, [1]. After a tornado in Lubbock, Texas, wound infections had these studies had heterogeneous populations with high rates 4.6 species per wound in hospitalized patients. Fungal cultures of confounding risk factors and primarily blunt-trauma from these patients yielded 3 unspeciated yeasts, 1 Rhodotorula, injuries. With prior antifungal exposure associated with non- and 8 molds [33]. In the Joplin tornado cohort with Apophyso- albicans Candida isolation and its decreased antifungal suscept- myces trapeziformis-necrotizing wound infections, both pediat- ibility, and no evidence of mortality from Candida or serial iso- ric patients and more than half of incident wounds in adults lation, it is difficult to recommend antifungal prophylaxis in also had Candida spp isolated [6, 7]. Although there are data those suffering penetrating trauma. The high rate of MDR to support environmental sources of wound infection isolates, bacterial and MWI coexistence in patients with Candida delayed recovery and resistance patterns of some later isolates wound involvement may favor a strong role for surgical de- also point to the possibility of low initial inoculum, or, more bridement [1–3, 6, 7, 33]. likely, nosocomial sources. More recent studies have reflected There is concern regarding increasing resistance within Can- the ongoing evolution of microbiology related to both wound dida spp. Overall, the MIC distribution of our first isolates 6 OFID Blyth et al � � Candida Relevance in Combat Casualties OFID 7 � � Table 5. In Vitro Susceptibilities as Determined by Sensititre YeastOne Antifungal Plate by CLSI, and AEI Interpretations for Most Frequently Isolated Candida Non-albicans Species Minimum Inhibitory Concentration (µg/mL) CLSI Interpretation (%) AEI Interpretation (%) Species Antifungal ≤0.008 0.015 0.03 0.06 0.12 0.25 0.5 1 2 4 8 64 128 S SDD I R S SDD I R C tropicalis (n = 10) Anidulafungin NA 3 6 1 NA NA 90 0 10 90 10 Micafungin 1 8 1 NA NA 90 0 10 NE NE NE NE Caspofungin 4 5 1 NA NA 90 0 10 NE NE NE NE Posaconazole 1 5 3 1 NA NA NE NE NE NE 60 40 Voriconazole 5 4 1 NA NA 90 10 0 90 10 Itraconazole NA 2 6 2 NA NA 20 80 0 NE NE NE NE Fluconazole NA NA NA NA 5 3 1 1 80 10 10 80 10 10 Amphotericin NA NA NA NA 10 NA NA 100 0 100 0 C glabrata (n = 7) Anidulafungin NA 1 4 1 1 NA NA 100 0 0 100 0 Micafungin 7 NA NA 100 0 0 100 0 Caspofungin 1 5 1 NA NA 100 0 0 NE NE NE NE Posaconazole 5 2* NA NA NE NE NE NE NE NE NE NE Voriconazole 3 2 2 NA NA NE NE NE NE NE NE NE NE Itraconazole NA 5 2 NA NA 0 71 29 NE NE NE NE Fluconazole NA NA NA NA 5 1 1 71 29 0 71 29 Amphotericin NA NA NA NA 7 NA NA 100 0 100 0 C parapsilosis (n = 6) Anidulafungin NA 6 NA NA 100 0 0 0 100 0 Micafungin 4 2 NA NA 100 0 0 0 100 0 Caspofungin 6 NA NA 100 0 0 NE NE NE NE Posaconazole 2 4 NA NA NE NE NE NE 100 0 Voriconazole 4 2 NA NA 100 0 0 100 0 Itraconazole NA 1 2 3 NA NA 100 0 0 NE NE NE NE Fluconazole NA NA NA NA 1 5 100 0 0 100 0 0 Amphotericin NA NA NA NA 6 NA NA 100 0 100 0 Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; CLSI, Clinical and Laboratory Standards Institute; I, intermediate; MIC, minimum inhibitory concentration; NA, not applicable; NE, not established; R, resistant; S, susceptible; SDD, susceptible-dose dependent. *MIC >8 µg/mL. MIC ≤0.015 µg/mL. Table 6. Clinical Characteristics, Number (%) of CLSI Versus AEI Susceptible and Resistant Isolates CLSI Interpretation AEI Interpretation Nonsusceptible Susceptible Nonsusceptible Susceptible Characteristic (n =6) (n = 125) (n = 18) (n = 113) Age, median (min-max) 23 (19–32) 23 (19–45) 26 (19–42) 23 (19–45) Mechanism of Injury IED blast 5 (83) 87 (70) 13 (72) 79 (70) Gunshot wound 1 (17) 23 (18) 4 (22) 20 (18) Non-IED blast 0 8 (6) 0 8 (7) Other 0 7 (6) 1 (6) 6 (5) ISS, median (min-max) 22 (8–66) 29 (14–50) 19.5 (10–50) 24 (8–66) Wound, AIS median (min-max) 4(2–5) 5 (2–5) 4.5 (2–5) 5 (2–5) Wound site 2 (33) 35 (28) 12 (67) 25 (22) Leg 0 13 (37) 6 (50) 7 (28) Arm 0 4 (11) 1 (8) 3 (12) Abdomen 1 (50) 1 (3) 2 (16) 0 Chest/back 0 1 (3) 1 (8) 0 Pelvis/groin 0 9 (26) 1 (8) 8 (32) Face/head 1 (50) 3 (9) 1 (8) 3 (12) Other 0 4 (11) 0 4 (16) Location of initial hospitalization Southern Afghanistan 4 (67) 69 (55) 12 (67) 61 (54) Eastern Afghanistan 1 (17) 43 (34) 4 (22) 40 (35) Iraq 0 8 (6) 1 (6) 7 (6) Other 1 (17) 5 (4) 1 (6) 5 (4) †† Mold wound infection 1 (17) 24 (19) 7 (39) 18 (16) † † †† Non-albicans species 4 (67) 25 (20) 18 (100) 11 (10) * Source of isolate †† Blood 2 (33) 15 (12) 5 (28) 12 (11) †† Wound 2 (33) 35 (28) 12 (67) 25 (22) †† Respiratory 2 (33) 61 (49) 1 (6) 62 (55) Intra-abdominal 0 5 (4) 0 5 (4) Other 0 9 (7) 0 9 (8) Clinically diagnosed infection 4 (67) 70 (56) 14 (78) 60 (53) †† Prior antifungal exposure 2 (33) 17 (14) 8 (44) 15 (13) Death 1 (17) 8 (6) 2 (11) 8 (7) Days from culture to death, median (min-max) 10 (10–10) 4.5 (0–71) 17 (17–17) 4.5 (0–71) Days from injury to death, median (min-max) 19 (19–19) 14.5 (1–76) 36 (29–43) 14.5 (1–76) Abbreviations: AEI, adjusted-European Committee on Antimicrobial Susceptibility Testing; AIS, abbreviated injury scale; CLSI, Clinical and Laboratory Standards Institute; IED, improvised explosive device; ISS, injury severity score; max, maximum; min, minimum; MWI, mold wound infection. P value <.05 in univariate analysis. †† P value <.01 in univariate analysis. * P value <.05 in multivariate analysis for AEI only (included MWI Y/N, Non-albicans Y/N, antifungal before, source of isolate including blood, wound, and respiratory). The number of isolates related to wound AIS was 2 and 33 for the CLSI nonsusceptible and susceptible, respectively, and 12 and 23 for AEI nonsusceptible and susceptible, respectively. The number of isolates related to days from culture/injury to death was 1 and 8 for the CLSI interpretations of nonsusceptible and susceptible, respectively, and 2 and 8 for the AEI interpretations. matches published epidemiological cutoff values [10]. Candida resistant C albicans isolates, few serial isolates with prolonged, albicans isolates were highly susceptible by both CLSI and AEI targeted antifungals, or increased non-albicans Candida spp re- criteria. We did not find that antifungal exposure was associated covered after antifungal exposure. Antifungal exposure was asso- with C albicans resistance. This may be related to our lack of ciated with nonsusceptibility within non-albicans Candida spp. 8 OFID Blyth et al � � Although prior studies have shown a direct relationship be- References tween infection-related mortality and rising antifungal MICs 1. Maegele M, Gregor S, Steinhausen E, et al. The long-distance tertiary air [10, 15, 39, 40], we did not find an association between antifun- transfer and care of tsunami victims: injury pattern and microbiological and psychological aspects. Crit Care Med 2005; 33:1136–40. gal nonsusceptibility and serial isolation, infection, or death. In 2. Kazancioglu R, Cagatay A, Calangu S, et al. The characteristics of infec- our population, very few patients with infection were treated tions in crush syndrome. Clin Microbiol Infect 2002; 8:202–6. with antifungal monotherapy to which the isolate was nonsus- 3. Warkentien T, Rodriguez C, Lloyd B, et al. Invasive mold infections fol- ceptible. These patients did not fare worse; however, there are lowing combat-related injuries. Clin Infect Dis 2012; 55:1441–9. 4. Weintrob AC, Weisbrod AB, Dunne JR, et al. Combat trauma-associated multiple limitations of this study that could affect our ability invasive fungal wound infections: epidemiology and clinical classifica- to detect a difference. These include the small number of non- tion. Epidemiol Infect [in press]. doi: 10.1017/S095026881400051X. susceptible isolates [39] and application of established criteria 5. Rodriguez CJ, Weintrob AC, Shah J, et al. Risk factors associated with invasive fungal infections in combat trauma. Surg Infect (Larchmt) defining pneumonia [16] used in the TIDOS project, which 2014; 15:521–6. do not require histopathology to more specifically attribute 6. Neblett Fanfair R, Benedict K, Bos J, et al. Necrotizing cutaneous mu- Candida isolates from respiratory specimens to actual infection. cormycosis after a tornado in Joplin, Missouri, in 2011. N Engl J Med 2012; 367:2214–25. This predefined criteria led to identifying 17 of 63 pulmonary 7. Weddle G, Gandy K, Bratcher D, et al. Apophysomyces trapeziformis in- isolates as associated with infection. In general, these findings fection associated with a tornado-related injury. Pediatr Infect Dis J support continued correlation of AST with clinical outcomes. 2012; 31:640–2. Overall, our data from combat-related injured military 8. Wolf DG, Polacheck I, Block C, et al. High rate of candidemia in pa- tients sustaining injuries in a bomb blast at a marketplace: a possible personnel support prior clinical and microbiologic studies of environmental source. Clin Infect Dis 2000; 31:712–6. fungal traumatic inoculations. In this population, Candida 9. Fares Y, El-Zaatari M, Fares J, et al. Trauma-related infections due to isolation is common and may be reflective of a population at cluster munitions. J Infect Public Health 2013; 6:482–6. 10. Pfaller MA, Andes D, Diekema DJ, et al. Wild-type MIC distributions, higher risk for infections with MDR bacteria, MWI, and death. epidemiological cutoff values and species-specific clinical breakpoints There was little resistance in Candida isolates. Nonetheless, for fluconazole and Candida: time for harmonization of CLSI and EU- non-albicans Candida spp were more likely to be isolated from CAST broth microdilution methods. Drug Resist Updat 2010;13:180–95. 11. Clinical and Laboratory Standards Institute. Reference Method for clinically significant sites such as blood and wounds. These iso- Broth Dilution Antifungal Susceptibility Testing of Yeasts; Fourth In- lates were associated with prior antifungal therapy and, of most formational Supplement. CLSI document M27-S4. Clinical and Labora- immediate clinical concern, decreased susceptibility to antifun- tory Standards Institute, Wayne, PA; 2012. gals. Without greater numbers of resistant Candida isolates as- 12. Subcommittee on Antifungal Susceptibility Testing (AFST) of the ESC- MID European Committee for Antimicrobial Susceptibility Testing sociated with infection, the significance of targeted antifungal (EUCAST). EUCAST definitive document EDef 7.1: method for the de- therapy and/or surgical interventions remains unclear. Further termination of broth dilution MICs of antifungal agents for fermenta- studies focusing on isolates associated with infection, including tive yeasts. Clin Microbiol Infect 2008; 14:398–405. 13. Arendrup MC, Cuenca-Estrella M, Lass-Florl C, et al. EUCAST techni- more resistant isolates, are needed to determine the clinical sig- cal note on the EUCAST definitive document EDef 7.2: method for the nificance and appropriate management of these infections. determination of broth dilution minimum inhibitory concentrations of antifungal agents for yeasts EDef 7.2 (EUCAST-AFST). Clin Microbiol Infect 2012; 18:E246–7. Acknowledgments 14. Pfaller MA, Chaturvedi V, Diekema DJ, et al. Clinical evaluation of the We are indebted to the Infectious Disease Clinical Research Program Sensititre YeastOne colorimetric antifungal panel for antifungal sus- TIDOS study team of clinical coordinators, microbiology technicians, data ceptibility testing of the echinocandins anidulafungin, caspofungin, managers, clinical site managers, and administrative support personnel for and micafungin. J Clin Microbiol 2008; 46:2155–9. their tireless hours to ensure the success of this project. 15. van Hal SJ, Chen SC, Sorrell TC, et al. Support for the EUCAST and Disclaimer. The views expressed are those of the authors and does not revised CLSI fluconazole clinical breakpoints by Sensititre(R) necessarily reflect the official views of the Uniformed Services University of YeastOne(R) for Candida albicans: a prospective observational cohort the Health Sciences, the Henry M. Jackson Foundation for the Advancement study. J Antimicrob Chemother 2014; 69:2210–4. of Military Medicine, Inc., National Institute of Health or the Department of 16. Tribble DR, Conger NG, Fraser S, et al. Infection-associated clinical out- Health and Human Services, the Department of Defense or the Departments comes in hospitalized medical evacuees after traumatic injury: Trauma of the Army, Navy or Air Force. Mention of trade names, commercial prod- Infectious Disease Outcome Study. J Trauma 2011; 71:S33–42. ucts, or organization does not imply endorsement by the U.S. Government. 17. De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive Financial support. This work (the Trauma Infectious Disease Out- fungal disease from the European Organization for Research and Treat- comes Study; IDCRP-024) was supported by the Infectious Disease Clinical ment of Cancer/Invasive Fungal Infections Cooperative Group and the Research Program, a Department of Defense program executed through the National Institute of Allergy and Infectious Diseases Mycoses Study Uniformed Services University of the Health Sciences. This project was been Group (EORTC/MSG) Consensus Group. Clin Infect Dis 2008; 46: funded by the National Institute of Allergy and Infectious Diseases, National 1813–21. Institute of Health (Inter-Agency Agreement Y1-AI-5072) and the Depart- 18. Copes WS, Champion HR, Sacco WJ, et al. The Injury Severity Score ment of the Navy under the Wounded, Ill, and Injured Program (HU001- revisited. J Trauma 1988; 28:69–77. 10-1-0014). 19. Gennarelli TA, Wodzin E. AIS 2005: a contemporary injury scale. Injury Potential conflicts of interest. All authors: No reported conflicts. 2006; 37:1083–91. All authors have submitted the ICMJE Form for Disclosure of Potential 20. Champion HR, Holcomb JB, Lawnick MM, et al. Improved character- Conflicts of Interest. ization of combat injury. J Trauma 2010; 68:1139–50. Candida Relevance in Combat Casualties OFID 9 � � 21. Pfaller MA, Chaturvedi V, Diekema DJ, et al. Comparison of the Sensi- European Committee on Antibiotic Susceptibility Testing (EUCAST) and titre YeastOne colorimetric antifungal panel with CLSI microdilution four commercial techniques. Clin Microbiol Infect 2005; 11:486–92. for antifungal susceptibility testing of the echinocandins against 29. European Committee on Antimicrobial Susceptibility Testing. Rationale Candida spp., using new clinical breakpoints and epidemiological cutoff documents on antifungal agents. Available at: http://www.eucast.org/ values. Diagn Microbiol Infect Dis 2012; 73:365–8. antifungal_susceptibility_testing_afst/rationale_documents_for_ 22. Cuenca-Estrella M, Gomez-Lopez A, Alastruey-Izquierdo A, et al. Com- antifungals/. Accessed 1 June 2014. parison of the Vitek 2 antifungal susceptibility system with the clinical 30. Murray CK, Wilkins K, Molter NC, et al. Infections complicating the and laboratory standards institute (CLSI) and European Committee on care of combat casualties during Operations Iraqi Freedom and Endur- Antimicrobial Susceptibility Testing (EUCAST) Broth Microdilution ing Freedom. J Trauma 2011; 71:S62–73. Reference Methods and with the Sensititre YeastOne and Etest tech- 31. Dau B, Oda G, Holodniy M. Infectious complications in OIF/OEF niques for in vitro detection of antifungal resistance in yeast isolates. J veterans with traumatic brain injury. J Rehabil Res Dev 2009;46: Clin Microbiol 2010; 48:1782–6. 673–84. 23. Alexander BD, Byrne TC, Smith KL, et al. Comparative evaluation of 32. Manolakaki D, Velmahos G, Kourkoumpetis T, et al. Candida infection Etest and sensititre yeastone panels against the Clinical and Laboratory and colonization among trauma patients. Virulence 2010; 1:367–75. Standards Institute M27-A2 reference broth microdilution method for 33. Gilbert DN, Sanford JP, Kutscher E, et al. Microbiologic study of wound testing Candida susceptibility to seven antifungal agents. J Clin Micro- infections in tornado casualties. Arch Environ Health 1973; 26:125–30. biol 2007; 45:698–706. 34. Benedict K, Park BJ. Invasive fungal infections after natural disasters. 24. Clinical and Laboratory Standards Institute. Reference Method for Emerg Infect Dis 2014; 20:349–55. Broth Dilution Antifungal Susceptibility Testing of Yeasts: Third Infor- 35. Horvath EE, Murray CK, Vaughan GM, et al. Fungal wound infection mational Supplement. CLSI document M27-S3. Clinical and Laboratory (not colonization) is independently associated with mortality in burn Standards Institute, Wayne, PA; 2008. patients. Ann Surg 2007; 245:978–85. 25. Clinical and Laboratory Standards Institute. Reference Method for 36. Moore EC, Padiglione AA, Wasiak J, et al. Candida in burns: risk factor Broth Dilution Antifungal Susceptibility Testing of Yeasts; Approved and outcomes. J Burn Care Res 2010; 31:257–63. Standard. CLSI document M27-A3. Clinical and Laboratory Standards 37. Mende K, Beckius ML, Zera WC, et al. Phenotypic and genotypic Institute, Wayne, PA; 2008. changes over time and across facilities of serial colonizing and infecting 26. European Committee on Antimicrobial Susceptibility Testing. Antifungal Escherichia coli isolate recovered from injured service members. J Clin agents. Breakpoint tables for interpretation of MICs (v 6.1). Available at: Microbiol 2014; 52:3869–77. http://www.eucast.org/clinical_breakpoints. Accessed 1 June 2014. 38. Cruciani M, de Lalla F, Mengoli C. Prophylaxis of Candida infections in 27. Arendrup MC, Cuenca-Estrella M, Lass-Florl C, Hope WW. Break- adult trauma and surgical intensive care patients: a systematic review points for antifungal agents: an update from EUCAST focussing on and meta-analysis. Intensive Care Med 2005; 31:1479–87. echinocandins against Candida spp. and triazoles against Aspergillus 39. Rex JH, Pfaller MA. Has antifungal susceptibility testing come of age? spp. Drug Resist Updat 2013; 16:81–95. Clin Infect Dis 2002; 35:982–9. 28. Cuenca-Estrella M, Gomez-Lopez A, Mellado E, et al. Correlation between 40. Pfaller MA. Antifungal drug resistance: mechanisms, epidemiology, and the procedure for antifungal susceptibility testing for Candida spp. of the consequences for treatment. Am J Med 2012; 125:S3–13. 10 OFID Blyth et al � �

Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Dec 1, 2014

There are no references for this article.