Background Invasive fungal wound infections (IFI) are a recognized threat for personnel who TAK-700 (Orteronel) sustain combat-related blast trauma in Afghanistan. culture growth without recurrent wound necrosis. Methods United States military personnel wounded during combat in Afghanistan (June 2009 – August 2011) were assessed for growth of mold from wound cultures and/or histopathological evidence of IFI. Identified patients were stratified based upon clinical wound appearance (with/without recurrent necrosis) and the resultant groups were compared for injury characteristics clinical management and outcomes. Results A total of 96 patients were identified: 77 with fungal elements on histopathology and/or fungal growth plus recurrent wound necrosis and 19 with fungal growth on culture but no wound necrosis after initial debridements. Injury patterns and severity were similar between the groups. Patients with recurrent necrosis had more frequent fevers and leukocytosis during the first two weeks post-injury and the majority received antifungal therapy compared to only three (16%) patients without recurrently necrotic wounds. Overall patients without recurrent wound necrosis had significantly TAK-700 (Orteronel) less operative procedures (p=0.02) shorter length of stay in the intensive care unit (p<0.01) and lower rates of high-level amputations (5% versus 20%) and deaths (none versus 8%) despite no or infrequent antifungal use. Conclusions The finding of molds on wound culture among patients with blast trauma in the absence of recurrently necrotic wounds on serial debridement does not require systemic antifungal chemotherapy. growth was comparable between the groups; however patients without recurrent necrosis had significantly more growth of at LRMC (p=0.03; Table 2). Table 2 Mycology Culture Results by Clinical Wound Appearance No. (%) Following Combat-Related Injuries 2009 Invasive Fungal Infection Management Only 16% of subjects without recurrent necrosis were prescribed antifungal therapy compared to 84% of patients with recurrently necrotic wounds (p<0.01; Table 3). Patients without recurrent necrosis who were prescribed amphotericin B (liposomal) also received it for a significantly shorter duration compared to subjects with recurrent wound necrosis (p=0.01). In addition the number of operating room visits for surgical debridements was increased (p=0.02) among patients with recurrently necrotic wounds. Table 3 Management and Clinical Outcomes among U.S. Military Personnel Injured in Combat (2009-2011) with Wound Cultures with Fungal Growth Clinical Outcomes Patients with recurrent wound TAK-700 (Orteronel) TAK-700 (Orteronel) necrosis had a significant increase in the total time spent in the intensive care unit (ICU; p<0.01; Table 3). Moreover there were a greater number of patients who sustained high-level amputations (i.e. total hip disarticulation or hemipelvectomy) within the group with recurrently necrotic wounds but the increase was not statistically significant. Although there were TAK-700 (Orteronel) TAK-700 (Orteronel) no deaths within the group without recurrent wound necrosis and six (7.8%) among the patients GRS with recurrently necrotic wounds the overall difference in crude mortality between the groups was not statistically significant. Discussion Although not as common as bacterial infections IFI have significant impact on the morbidity and mortality of wounded military personnel.4 11 Due to the progressive and serious nature of trauma-related IFI there is general agreement that early diagnosis aggressive serial debridement minimization of immunosuppression and treatment with systemic antifungal therapy comprise the soundest strategy for management of this disease.4 7 8 14 The clinical significance of cultures growing mold without the clinical stigmata of IFI presents challenges in determining the appropriate management. While we recognize the critical need for early empiric antifungal therapy to properly manage IFI treatment should be based upon clinical indicators of the disease in order to avoid the unnecessary use of intravenous antifungals as they may result in nephrotoxicity and hepatotoxicity. Consequently the aim of this study was to compare injury patterns baseline clinical characteristics clinical mycology.