582 Invasive Fungal Infection Increases Mortality Risk After Burn Injury

TL;DR

Invasive fungal infections significantly increase mortality in burn patients, with aspergillus being particularly deadly.

Contribution

This is the largest study to date evaluating mortality associated with invasive fungal infections in burn patients using a multi-institutional dataset.

Findings

IFI in burn patients is associated with an 18.5% mortality rate compared to 1.9% in controls.

Aspergillus infection has the highest mortality rate of 26.7% among burn patients with IFI.

Mortality increases with TBSA, reaching 33.1% for burns >50% TBSA.

Abstract

While invasive fungal infections (IFI) can be deadly for any hospitalized patient, a high-risk subset are those with burn injuries due to their inherently immunocompromised state. There is a paucity of literature on IFI in this population, making it difficult to evaluate the true risk. This novel study captures data from across the US using a commercially available multi-institutional dataset derived from electronic health record data and is the largest study to date evaluating mortality associated with IFI in burn patients.

Inclusion criteria identified all patients with an ICD diagnosis of a burn from 2002-2024; IFI was defined as an ICD diagnosis of fungal mycoses with systemic antifungal treatment. This cohort was matched for gender, age and TBSA and compared to a control cohort of burn patients without mycoses or antifungal treatment. TBSA was further divided into three subcategories of < 10%, 10-49% and >50% TBSA burns to analyze differences in mortality.

The IFI cohort contained 3,326 patients while the control cohort was comprised of 706,463 patients. After matching, the risk of mortality for all IFI in burn patients was 18.5% compared to 1.9% in controls (RR: 9.8, 95% CI 7.2-13.2; p <.0001). Additionally, when stratified by TBSA there was a stepwise increase in mortality with TBSA: 21.6% for < 10% TBSA (RR: 12.4, 95% CI 6.6-23.4; p <.0001), 29.0% for 10-49% TBSA (RR: 2.7, 95% CI 1.8-4.2; p <.0001) and 33.1% for >50% TBSA (RR: 1.3, 95% CI 0.9-1.9; p=.02). Stratifying by organism, the 3 most common and deadly IFI among all burn patients were aspergillus, invasive candida and other mycoses with mortality rates of 26.7%, 22.7%, 20.0% respectively. Notably, aspergillus had the highest mortality rate of 26.7% (RR: 6.6, 95% CI 3.5-12.5; p <.0001) and when stratified by TBSA it substantially increased: 21.6% for < 10% TBSA (RR: 1.9, 95% CI 0.9-3.8; p <.06) and 51.9% for >50% TBSA (RR: 1.4, 95% CI 0.8-2.6; p=.3).

In all burns, IFI is associated with a nearly 10-fold increase in mortality. An incremental increase is noted when stratified by TBSA and surprisingly, even small burns with IFI have an over 20% risk of mortality. All IFI are high risk, with survival differences based on organism, but aspergillus infection is associated with mortality in over ¼ of infected patients. When using a large deidentified database, associations may be drawn, but we cannot conclude that mortality was caused solely by IFI. Additionally, the lack of specificity in ICD-coding for fungal infections is problematic as large cohorts (other mycoses and unspecified mycoses) could be representing a wide range of fungal infections and we cannot identify which organisms are represented (i.e. curvularia, mucor, fusarium, etc.).

IFI in burn patients present a challenging and often deadly problem; as the largest and most comprehensive study of IFI in burns, this study supports the early detection and consideration of antifungal prophylaxis in burns.

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