RESUMO
INTRODUCTION: The aggressive and timely treatment of post-traumatic fungal infections is the most efficacious way to reduce morbidity and mortality. Compared to the military trauma population, studies reporting on fungal infections in civilian trauma are not well described. The purpose of this study was to describe characteristics of civilian trauma patients who developed fungal infections and to identify common risk factors and report any delays between injury and treatment. METHODS: This was a five-year (1/1/2013-3/1/2018) retrospective, descriptive study across six level 1 trauma centers. All consecutively admitted trauma patients (≥18 years) with laboratory-confirmed fungal wound infections were included. Patients with solely candida wound isolates were excluded. Patient demographics, clinical wound and infection characteristics, organisms cultured, treatment modalities, length of stay, in-hospital mortality, and any diagnostic or treatment delays were described. RESULTS: Of the 54,521 trauma patients screened for fungal infection, 12 were identified. All patients suffered major injuries after blunt trauma (abbreviated injury score 3-5) and sustained wound contamination, and in nine patients, the cause of injury was motor vehicle. Six had open wounds/fractures on admission. The geographical region with the highest rate of fungal infection was Texas (n = 7), followed by Kansas (N = 3), then Missouri (N = 2). First symptoms of infection (leukocytosis or fever (n = 10)) presented a median of 6.3 (4.1-9.8) days after injury. Wound management entailed a combination of debridements (n = 8), negative pressure wound therapy (n = 9), amputation (n = 6), and antifungal treatment (n = 10). All fungal isolates identified from the wound site were hyphomycetes. A median of 2.1 (1.8-4.0) days passed from diagnosis to first antifungal treatment, and 3 patients died. CONCLUSIONS: Our study shows the challenges surrounding diagnosis and treatment of fungal infections secondary to trauma. Non-specific fungal infection symptoms, such as leukocytosis and fever, typically presented a week after injury. Vigilance for investigating risk factors and infection symptoms may help clinicians with more timely management of trauma patients with a severe fungal infection.
Assuntos
Antifúngicos/uso terapêutico , Desbridamento , Fungos Mitospóricos/isolamento & purificação , Micoses , Infecção dos Ferimentos , Ferimentos não Penetrantes/complicações , Adulto , Amputação Cirúrgica/métodos , Amputação Cirúrgica/estatística & dados numéricos , Desbridamento/métodos , Desbridamento/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação/estatística & dados numéricos , Masculino , Micoses/diagnóstico , Micoses/epidemiologia , Micoses/fisiopatologia , Micoses/cirurgia , Tratamento de Ferimentos com Pressão Negativa/métodos , Fatores de Risco , Centros de Traumatologia/estatística & dados numéricos , Estados Unidos/epidemiologia , Infecção dos Ferimentos/tratamento farmacológico , Infecção dos Ferimentos/epidemiologia , Infecção dos Ferimentos/microbiologia , Infecção dos Ferimentos/cirurgia , Ferimentos não Penetrantes/diagnóstico , Ferimentos não Penetrantes/epidemiologiaRESUMO
BACKGROUND: To determine the clinical outcomes of perimesencephalic subarachnoid hemorrhages based on the computed tomography (CT) bleeding patterns. METHODS: This retrospective cohort study included: (1) patients (≥18 years) admitted to a comprehensive stroke center (January 2015-May 2018), (2) with angiography-negative, nontraumatic subarachnoid hemorrhage in a perimesencephalic or diffuse bleeding pattern, and (3) had CT imaging performed in ≤ 72 hours of symptom onset. Patients were stratified by location of bleeding on CT: Peri-1: focal prepontine hemorrhage; Peri-2: prepontine with suprasellar cistern +/- intraventricular extension; and diffuse. RESULTS: Of the 39 patients included, 13 were Peri-1, 11 were Peri-2, and 15 were diffuse. The majority were male (nâ¯=â¯26), with a mean (standard deviation) age of 55.3 (11.3) years, who often presented with headache (nâ¯=â¯37) and nausea (nâ¯=â¯28). Overall, patients in Peri-1 were significantly less likely to have hydrocephalus compared to Peri-2 and dSAH (P= .003), and 4 patients required an external ventricular drain. Five patients developed symptomatic vasospasm. Patients in Peri-1, compared to Peri-2 and diffuse, had a significantly shorter median neuro critical care unit length of stay (LOS) and hospital LOS. Most patients (nâ¯=â¯35) had a discharge modified Rankin Score between 0 and 2 with no significant differences found between groups. CONCLUSION: These data suggest that patients with the best clinical course were those in Peri-1, followed by Peri-2, and then diffuse. Because these patients often present with similar clinical signs, stratifying by hemorrhage pattern may help clinicians predict which patients with perimesencephalic subarachnoid hemorrhage develop complications.