Incidence of systemic fungal infection and related mortality following severe burns

doi:10.1016/j.burns.2008.04.007

Burns

Volume 34, Issue 8, December 2008, Pages 1108-1112

https://doi.org/10.1016/j.burns.2008.04.007 Get rights and content

Abstract

Advancements in burn care therapy have extended survival of seriously burned patients, exposing burn patients to increased risk of infectious complications, notably fungal infections. We performed a 12-year review of autopsied patients with severe burns for the presence of fungal infection at the US Army Institute of Surgical Research Burn Center between February 1991 and November 2003. The primary goal was to identify the relationship between fungal element noted in autopsy and mortality, and to determine contributing factors that increase a patient's susceptibility to fungal infection. A total of 228 deaths (6.1%) resulted from the 3751 admissions of which 97 underwent autopsy. Fungal elements were identified on histopathology in 44% (43 of 97) of autopsied patients with an attributable mortality of 33% (14 of 43). Aspergillus and Candida were the most frequently recovered fungi, but Aspergillus was recovered in 13 of the 14 cases with fungus identified as an attributable cause of death. The most common sites of infections with attributable mortality were wounds (86%) and the pulmonary system (14%). Total body surface area (TBSA) burn and length of stay (survival after burn) were identified as contributing factors for the incidence of fungal element in autopsy on ROC curve analysis. More severely injured patients with greater %TBSA burn injury and full-thickness burns require a longer recovery period resulting in a longer hospital stay. The propensity for fungal infection increases the longer the wound is present. Therefore, the development of products to close the wound more rapidly, improvement in topical antifungal therapy with mold activity for treating wounds, and implementation of appropriate systemic antifungal therapy may improve outcome for severely injured burn victims susceptible to fungal infections.

Introduction

Advances in the management of burn patients have improved overall care; however, infectious complications remain a major contributor to morbidity and mortality. Improvements in topical antimicrobial therapy, systemic antimicrobial agents, and infection control procedures have primarily focused on the management of bacterial infections. These interventions have resulted in a decrease in bacterial infections, but fungal infections remain relatively stable [1]. Traditionally, management of fungal infections was limited because of diagnostic challenges and a limited armamentarium of antifungal agents. However, the introduction of novel and less toxic antifungals has ushered in an era of improved fungal care. It has been shown that identification of pathogens purely by histopathogic diagnosis is inadequate due to varying fungal genus and species resistance profiles to antifungals [2]. Other recent publications revealed the clinical importance of adequately managing fungal infections especially at total body surface area (TBSA) burn between 30 and 60% due to increased mortality [3], [4]. However, extensive study of the attributable mortality of fungal infections has not been performed. Herein, we report a 12-year review of autopsied patients with burn injuries to identify the attributable mortality due to fungal infections and to determine the potential contributing factors that increase a patient's susceptibility to fungal infection and mortality.

Section snippets

Materials and methods

This is a retrospective medical records review of all autopsy reports from burn patients treated at the U.S. Army Institute of Surgical Research (USAISR) Burn Center at Brooke Army Medical Center (BAMC), Fort Sam Houston, TX over a 12-year period (February 1991–November 2003). Only patients with thermal burns were included in the analysis and those without autopsies were excluded. The management strategies for these patients were described previously [3]. Data obtained included cause of death,

Results

Two hundred and twenty-eight (6.1%) of the 3751 patients admitted to the burn center during February 1991–November 2003 died. Autopsy was performed on 97 of these patients (42.5%). There was no difference in age, %TBSA burn, %FTB, gender or days from burn to death between those patients who did and those who did not undergo autopsy (data not shown). Of those who underwent an autopsy, the median age was 49.0 (range, 2–95), with 27 women (28%), median TBSA burn of 57.5% (range, 1–97), and median

Discussion

Infections remain a primary cause of morbidity and mortality in patients who are burned with fungal infections being among the main pathogens. This study reviewed 97 autopsies over a 12-year period and showed that 44% had fungal elements on histopathology. Fourteen (14%) of the 97 autopsy reports indicated fungal infections were associated with attributable mortality. Aspergillus and Candida were the most frequently recovered fungi; however, in cases where fungus was an attributable cause of

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^☆: Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of Defense or the U.S. government. This work was prepared as part of their official duties and, as such, there is no copyright to be transferred.

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Incidence of systemic fungal infection and related mortality following severe burns☆

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Burns

Am J Infect Control

Burns

Am J Surg

Fungal burn wound infection: a 10-year experience

Arch Surg