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Trauma Related Infections

Improving the prevention and clinical management of infections complicating battlefield trauma, particularly blast trauma, remains one of the highest priorities of the DoD. A further challenge in the care of patients with complex wounds and polytrauma is the occurrence of virulent and multidrug-resistant pathogens.

Research Area Description 

The primary aims of the Trauma-Related Infections Research Area are strategically focused to address knowledge gaps in the prevention and clinical management of combat-related infections. Specifically, research priorities include blast injuries, multidrug-resistant bacterial infections, long-term outcomes and quality of life, Joint Trauma System (JTS) clinical practice guidelines, and antibiotic stewardship. Since inception of the research area, the centerpiece protocol remains the Trauma Infectious Disease Outcomes Study (TIDOS), which is led by Dr. David Tribble. In brief, TIDOS systematically collected information on the medical management, microbiology, and infectious outcomes from military personnel wounded during deployment from June 2009 through December 2014. Infection-related follow-up data after hospital discharge continues to be captured from cohort enrollees through the Military Health System Data Repository. Data are also collected for enrollees who have entered Veterans Affairs (VA) health care through collaboration with the VA St. Louis Health Care System under the leadership of Dr. Jay McDonald.

In 2018, the 3rd Japan-US Technical Information Exchange Forum on Blast Injury brought together experts to share both knowledge and experiences related to blast trauma from across the globe. TIDOS investigators attended the meeting and presented information on blast wound infection epidemiology and microbiology. Findings from TIDOS analyses were also presented at the 2018 Military Health System Research Symposium session on minimizing the impact of wound infections following blast-related injuries.

Among combat casualties, extremity wounds are not only the most common type of injury, but are frequently complicated by infections. During 2018, an analysis to examine the effectiveness of specific antimicrobial regimens related to the treatment of deep soft-tissue infections was completed. While less common, non-extremity wound infections are also a focus of TIDOS analyses. One recently completed analysis on genitourinary injuries and urinary tract infections was conducted in collaboration with the VA St. Louis Health Care System. Presently, examination of the risk factors for intra-abdominal infections is underway.

As invasive fungal wounds infections (IFIs) are associated with substantial morbidity among blast casualties, early diagnosis is critical for effective management and improved outcomes. The IFI Molecular Diagnostics Protocol, led by Dr. Anuradha Ganesan and funded under the Defense Medical Research and Development Program, assesses molecular diagnostics methods to support earlier diagnoses with increased accuracy. Following a comprehensive review by subject-matter experts, a technical report presenting findings of the assessment of a polymerase chain reaction (PCR)-based assay was presented to the JTS for consideration in review of JTS IFI practice guidelines. Additional evaluation of formalin-fixed surgical pathology tissue specimens from IFI patients diagnosed based on culture findings and not histopathology is underway to further assess the utility of the PCR-based assay.

Another serious complication of trauma is osteomyelitis, which is generally characterized by multiple surgeries, extended use of antibiotics, and lengthy hospitalizations and ambulatory care. The Trauma-Associated Osteomyelitis protocol, led by Dr. Tribble, evaluated risk factors for the development of osteomyelitis among combat casualties with open fractures of the tibia, femur, and arm long bones. Published analyses provide risk factors for initial and recurrent tibial osteomyelitis. Collaboration with the VA St. Louis Health Care System is also investigating long-term outcomes in these patients.   

During 2018, numerous analyses were also completed under the TIDOS Multidrug-Resistant and Virulent Organisms (MDR/ VO) Trauma Infections initiative, which is funded through the Military Infectious Diseases Research Program and led by Dr. Katrin Mende. The Initiative involves a collaborative effort across multiple DoD laboratories (Walter Reed Army Institute of Research, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Brooke Army Medical Center) with the goal of maximizing the understanding of complex polymicrobial wounds through use of clinical data connected to the TIDOS Microbiology Repository. Analyses being planned will further examine the interaction of common wound bacteria (e.g., ESKAPE pathogens), as well as assess clinical outcomes in relation to wound microbiology and biofilm formation.

Key Studies

IDCRP-024: Trauma Infectious Disease Outcomes Study (TIDOS)

The development of infectious complications among military personnel following combat-related trauma remains a frequent occurrence.  As military personnel shifted to different operational theaters, injury patterns, severity, and mechanisms changed resulting in unexpected complications, such as the increased number of cases of invasive fungal infections (IFIs) among combat casualties who sustained complex dismounted blast trauma.  Moreover, the rising proportion of colonization by multidrug-resistant organisms (MDROs) creates further difficulties for clinicians.  Using prospective data gained from a cohort of military personnel with deployment-related injuries has provided further understanding of risk factors, treatment strategies, and outcomes associated with infectious complications and support improvement in the prevention and management of infections.  

On June 1, 2009, the U.S. Department of Defense (DoD) – Department of Veterans Affairs, Trauma Infectious Disease Outcomes Study (TIDOS) was initiated.  This ongoing multisite project is an observational cohort study of short- and long-term infectious complications among U.S. military personnel with traumatic injuries sustained during deployment.  Enrolled patients are prospectively followed for a period of five years.  Patients are eligible for inclusion if they are either active duty personnel or DoD beneficiaries, at least 18 years of age, injured during deployment requiring medical evacuation to Landstuhl Regional Medical Center (LRMC) in Germany before transfer to a participating U.S. military hospitals, and provide informed consent (or surrogate consent through legally authorized representative).  In addition, as part of TIDOS, bacterial isolates collected from wounded military personnel are stored in a repository for research purposes.  In recent years, TIDOS microbiology projects have expanded to include analyses investigating bacterial antagonism in wounds, anaerobic bacterial infections, presence of antibiotic resistance genes/virulence mechanisms and their association with antibiotics and clinical outcomes, and biofilm dispersal.  Overall, the TIDOS team has continued efforts to provide information to the U.S. Army Institute of Surgical Research Joint Trauma System in support of clinical practice guidelines and process improvement initiatives.

IDCRP-077: The Evaluation of Molecular and Antigen Based Techniques for the Identification of Invasive Skin and Soft Tissue Infections Due to Fungi

IDCRP-044: Case-Control Study of Osteomyelitis Risk Factors and Clinical Outcome Predictors Following an Operation Iraqi Freedom/ Operation Enduring Freedom Related Orthopedic Injury

IDCRP-072: Treatment Protocol for the Use of Arbekacin in Adult Patients with Infections Caused by Multidrug-resistant Bacteria

Military Impact

The research area’s aims and objectives continue to be responsive to priorities of the DoD JTS and provide important information during inter-war periods by improving the understanding and best practices of infection-related issues following battlefield injury. The strengths and opportunities presented by this research area present a robust platform to support development and refinement of evidence-based clinical practice guidelines for the management of combat trauma-related infections during future conflicts.

Highlights / Key Findings

  • Among patient with blast trauma, approximately one-fourth develop at least one trauma-related infection, with extremity wound infections being the most frequent.

  • In a MDR/VO Trauma Infections Initiative analysis, 237 Klebsiella pneumoniae isolates were examined and multidrug resistance was associated with prior use of fluoroquinolones and anti-pseudomonal penicillin.

  • Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 21% developed at least one urinary tract infection.

  • Patients with open femur fractures characterized by substantial loss of muscle or dead muscle have high risk of developing osteomyelitis.

  • IFI Molecular Diagnostics PCR-based assay had high specificity (99%) and sensitivity (83%) in tissues with documented angioinvasion when compared to histopathology as the reference standard.

Partners and Collaborators

IDCRP collaborates with investigators across various specialties (e.g., infectious disease, trauma surgery, and orthopedics) and commands at Landstuhl Regional Medical Center (LRMC), Walter Reed National Military Medical Center (WRNMMC), San Antonio Military Medical Center (SAMMC), US Army Institute for Surgical Research (USAISR), Walter Reed Army Institute of Research, Naval Medical Research Center, St. Louis Veterans Affairs (VA) Medical Center, and the Uniformed Services University of the Health Sciences. 

TIDOS US-UK Collaboration

The primary aim of the US-UK Military Combat Trauma Extremity Wound Infection Comparative Analysis is to inform future guidance and real-time tools for combat-related wound infection surveillance, prevention, and treatment. Both forces have sustained significant number of complex blast injuries, increasing the risk of infectious complications. Similarly, both militaries have relied on combat trauma registries to inform real-time improvements in prevention and management of battlefield injuries.  System-wide efforts have also been undertaken by both militaries to survey and analyze wound infections (US - Trauma Infectious Disease Outcomes Study [TIDOS]; UK - Wound Infection Surveillance Program or WISP).   Many surgical and medical practices are approached similarly; however, there are important differences including medevac/patient movement, damage control orthopedic surgery, wound care (e.g., negative pressure wound therapy; NPWT), and post-injury antibiotic prophylaxis selection that warrant collaborative analyses. Joint proposal and data-sharing agreements are currently under review. Initial analysis will focus on findings and management approaches for blast-related invasive fungal wound infections which affected both forces.

Annual Reports

Trauma-Related Infections Research Area 2017 Annual Report 

Publications 2018

Tribble DR, Krauss M, Murray CK, Warkentien TE, Lloyd BA, Ganesan A, Greenberg L, Xu J, Li P, Carson ML, Bradley W, Weintrob AC, and the IDCRP TIDOS Group. Epidemiology of Trauma-related Infections among a Combat Casualty Cohort Following Initial Hospitalization: The Trauma Infectious Disease Outcomes Study. Surgical -- Featured by the Blast Injury Research Program 

Tribble DR, Lewandowski LR, Potter BK, Petfield J, Stinner D, Ganesan A, Krauss M, Murray CK, and the Trauma Infectious Disease Outcomes Study Group. Osteomyelitis Risk Factors Related to Combat Trauma Open Tibia Fractures: A Case-Control Analysis. Journal of Orthopaedic Trauma. doi: 10.1097/BOT.0000000000001225 

McDonald JR, Liang SY, Maalouf S, Li P, Murray CK, Weintrob AC, Schnaubelt ER, Kuhn J, Ganesan A, Bradley W, Tribble DR, and the IDCRP TIDOS Group. Infectious Complications after Deployment Trauma: Following Wounded United States Military Personnel into Veterans Affairs Care. Clinical Infectious Diseases. doi: 10.1093/cid/ciy280

Lloyd BA, Murray, CK, Shaikh F, Carson ML, Blyth DM, Schnaubelt ER, Whitman T, Tribble DR, and the IDCRP TIDOS Group.  Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries. Military Medicine. 
doi: 10.1093/milmed/usx125  

Weintrob AC, Murray CK, Xu J, Krauss M, Bradley W, Warkentien TW, Lloyd BA, Tribble DR and the IDCRP TIDOS Group. Early Infections Complicating the Care of Combat Casualties from Iraq and Afghanistan. Surgical Infections. 2018; 19(3): 286-297.  

Heitkamp RA, Li P, Mende K, Demons ST, Tribble DR, Tyner SD.  Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection. Surgical Infections. 2018; 19(1):95-103. 

Presentations 2018

Mende K, Mangum LC, Akers KS, Demons ST, Hinkle MK, Watters CM, Simons MP, Stewart L, Tyner SD, Tribble DR. Microbial Threats Associated with Combat-Related Extremity Wounds: The MDR/VO Trauma Infections Initiative.  2018 ASM Microbe, 7-11 June 2018, Atlanta, GA. [Poster #AAR LB8] -- Featured in Healio

Publications 2016-2017

Lloyd BA, Murray, CK, Shaikh F, Carson ML, Blyth DM, Schnaubelt ER, Whitman T, Tribble DR, and the IDCRP TIDOS Group. Early Infectious Outcomes after Addition of Fluoroquinolone or Aminoglycoside to Posttrauma Antibiotic Prophylaxis in Combat-Related Open Fracture Injuries. Journal of Trauma and Acute Care Surgery. 2017; 83(5):854-861.

Tribble DR, Li P, Warkentien T, Lloyd BA, Schnaubelt ER, Ganesan A, Bradley W, Aggarwal D, Carson ML, Weintrob AC, and Murray CK. Impact of Operational Theater on Combat and Noncombat Trauma-Related InfectionsMilitary Medicine. 2016; 181(10): 1258-1268.

Mende K, Beckius ML, Zera WC, Yu X, Li P, Tribble DR, and Murray CK for the IDCRP TIDOS Investigative Team. Lack of Doxycycline Antimalarial Prophylaxis Impact on Staphylococcus aureus Tetracycline ResistanceDiagnostic Microbiology and Infectious Disease. 2016; 86(2):211-22. 

White BK, Mende K, Weintrob AC, Beckius ML, Zera WC, Lu D, Bradley W, Tribble DR, Schnaubelt E, and Murray CK on behalf of the IDCRP TIDOS Group. Epidemiology and Antimicrobial Susceptibilities of Wound Isolates of Obligate Anaerobes from Combat CasualtiesDiagnostic Microbiology and Infectious Disease.  2016; 84(2): 144-150.

Lewis CJ, Li P, Stewart L, Weintrob AC, Carson ML, Murray CK, Tribble DR, and Ross JD.  Tranexamic Acid in Life-Threatening Military Injury and the Associated Risk for Infectious Complications.  British Journal of Surgery.  2016; 103(4): 366-373.

Gilbert LJ, Li P, Murray CK, Yun HC, Aggarwal D, Weintrob AC, Tribble DR, and the IDCRP TIDOS Group.  Multidrug-Resistant Gram-Negative Bacilli Colonization Risk Factors among Trauma Patients. Diagnostic Microbiology and Infectious Diseases. 2016; 84(4): 358-360

Lloyd, B. A., et al. (2017). Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone. Mil Med 182(S1): 346-352. 

Campbell, W. R., et al. (2017). Multi-Drug–Resistant Gram-Negative Infections in Deployment-Related Trauma Patients. Surg Infect (Larchmt) 18(3): 357-367. 

Cardile AP, Woodbury RL, Becerra SC, et al. Activity of norspermidine on biofilms of multidrug-resistant clinical isolates associated with persistent extremity wound infections. Advances in Microbiology, Infectious Diseases and Public Health: Subseries of Advances in Experimental Medicine and Biology. 2017;973:53-70.

Yabes JM, White BK, Akers KS, Set al. In vitro activity of Manuka honey and polyhexamethylene biguanide on filamentous fungi and toxicity to human cells.  Medical Mycology. 2017;55(3):334-343.

Campbell WR, Li P, Whitman TJ, et al. Multi-drug-resistant Gram-negative infections in deployment-related trauma patients. Surgical Infections. 2017; 18(3): 357-367.

Mende K, Beckius ML, Zera WC, et al. Low prevalence of carbapenem-resistant Enterobacteriaceae among wounded military personnel. U.S. Army Medical Department Journal.  2017; July-September (2-17):12-17.

Presentations 2016-2017

ID Week 2016, October 26-30, 2016, New Orleans, LA

  1. Poster #1475: Lloyd BA, Murray CK, Shaikh F, et al.  Addition of Fluoroquinolones or Aminoglycosides to Post-Trauma Antibiotic Prophylaxis Does Not Decrease Risk of Early Osteomyelitis. 

  2. Poster #375: Campbell WR, Li P, Whitman TJ, et al. Characteristics and Predictive Factors for Multidrug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients.

  3. Poster #326: Patterson SB, Mende K, Li P, et al.  Stenotrophomonas maltophilia Resistance in Military Trauma Patients. 

  4. Poster #317: Patterson SB, Mende K, Li P, et al.  Clinical Characteristics of a Military Trauma Cohort with Stenotrophomonas maltophilia Infection. 

  5. Poster #1158: Stewart L, Shaikh F, Bradley W, et al. Microbiological Profile for Combat-related Extremity Wound Infections: Trauma Infectious Disease Outcomes Study 2009-2012.

DoD Blast Injury Research Program International State-of-the-Science Meeting on Minimizing the Impact of Wound Infections Following Blast-Related Injuries. 29 November - 1 December 2016, Arlington, VA

  1. [Oral presentation]: Tribble DR. Trauma Infectious Disease Outcomes Study (TIDOS): Blast Trauma Wound Infection Epidemiology & Microbiology.

  2. [Oral presentation]: Ganesan A. Combat-Related Invasive Fungal Wound Infections among U.S. Blast Casualties.

  3. [Oral presentation]: Stewart L. Assessment and Classification of Combat-Related Polytraumatic Extremity Wounds and Infectious Outcomes: Trauma Infectious Disease Outcomes Study 2009-2012. 

  4. [Oral presentation]: Mende K. Microbiological Profile for Combat-related Extremity Wound Infections: Trauma Infectious Disease Outcomes Study 2009-2012.

2017 ASM Microbe, June 1-5, 2017, New Orleans, LA

  1. Poster: Heitkamp R, Demons S, Li P, et al. The Diversity of Enterococcus Strains from Combat Wounds and Strain-based Patient Outcomes.

2017 Military Health System Research Symposium, August 27-30, 2016, Kissimmee, FL

  1. Oral Presentation: Stewart L, Shaikh F, Bradley W, et al. Combat-Related Extremity Wound Infection Risk Factors: Trauma Infectious Disease Outcomes Study 2009-2012. 

  2. Oral Presentation: Tribble DR, Potter BK, Lewandowski LR, et al. Osteomyelitis Risk Factors among Combat-Related Open Tibia Fractures.

  3. Poster #234: Mangum LC, Garcia GR, Tribble DR, et al. Biofilm Formation Capacity among Enterococcus species Isolates from Clinical Wound Infections of Injured US Military Personnel.

  4. Poster #224: Mende K, Mangum LC, Akers KS, et al. The Multidrug-Resistant and other Virulent Organisms (MDR/VO) Trauma Infections Initiative: 2017 Update. 

  5. Poster #228:  Ganesan A, Shaikh F, Peterson P, et al. U.S Combat-related Invasive Fungal Wound Infection (IFI) Epidemiology: Afghanistan Theater 2009-2014. 

  6. Poster #229: Heitkamp R, Demons S, Li P, et al. Enterococcus Diversity in Extremity Trauma Wounds and Strain-based Patient Outcomes. 

U.S. Army/U.S. Air Force American College of Physicians Chapter Meeting, September 7-9, 2017, JBSA Fort Sam Houston, TX

  1. Podium Presentation. Ford M, Mende, K, Kaiser SJ, et al. Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated from Operations Enduring Freedom and Iraqi Freedom Trauma Patients.

ID Week 2017, October 4-8, 2017, San Diego, CA

  1. Oral Presentation: Ganesan A, Shaikh F, Peterson P, et al. U.S. Combat-Related Invasive Fungal Wound Infection (IFI) Epidemiology: Afghanistan Theater 2009-2014.

  2. Poster #1128:  Jackson B, Liang ST, Kuhn J, et al. Urinary Tract Infections after Combat-Related Genitourinary Trauma.

  3. Poster #401: Campbell WR, Li P, Carson ML, et al. Characteristics and Predictive Factors for Multidrug-Resistant Gram-Negative Infections Following Deployment-Related Trauma. I

  4. Poster #403:  Ford M, Mende, K, Kaiser SJ, et al. Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated from Operations Enduring Freedom and Iraqi Freedom Trauma Patients.

  5. Poster #160:  Keaton N, Mende K, Beckius ML, et al. Antifungal Resistance Patterns in Molds Isolated from Wounds of Trauma OEF/OIF/OND and Burn Patients. 

Publications 2011-2015

Tribble DR, Conger NG, Fraser S, Gleeson TD, Wilkins K, Antonille T, Weintrob A, Ganesan A, Gaskins LJ, Li P, Grandits G, Landrum ML, Hospenthal DR, Millar EV, Blackbourne LH, Dunne JR, Craft D, Mende K, Wortmann GW, Herlihy R, McDonald J, and Murray CK. Infection-associated clinical outcomes in hospitalized medical evacuees after traumatic injury: trauma infectious disease outcome study. Journal of Trauma. 2011 Jul;71(1 Suppl):S33-S42.

Tribble DR, Lloyd B, Weintrob A, Ganesan A, Murray CK, Li P, Bradley W, Fraser S, Warkentien T, Gaskins LJ, Seillier-Moiseiwitsch F, Millar EV, Hospenthal DR; and the IDCRP TIDOS group. Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries. Journal of Trauma. 2011 Aug;71(2 Suppl 2):S299-S306.

Warkentien T, Rodriguez C, Lloyd B, Wells J, Weintrob A, Dunne JR, Ganesan A, Li P, Bradley W, Gaskins LJ, Seillier-Moiseiwitsch F, Murray CK, Millar EV, Keenan B, Paolino K, Hospenthal DR, and Tribble DR for the IDCRP TIDOS Group. Invasive Mold Infections following Combat-related Injuries. Clinical Infectious Diseases. 2012; 55(11):1441-1449.            

Tribble DR, Rodriguez C, Warkentien T for the IDCRP TIDOS Investigative Team. Mucormycosis After a Tornado in Joplin, Missouri. New England Journal of Medicine. 2013; 368(11):1067. [letter to the editor]

Ganesan A, Crawford K, Mende K, Murray CK, Lloyd BA, Ellis M, Tribble DR, and Weintrob AC. Evaluation for a Novel Methicillin Resistance (mecC) Homologue in Methicillin-Resistant Staphylococcus aureus Isolates Obtained from Injured Military Personnel. Journal of Clinical Microbiology. 2013; 51(9):3073-3075.

Weintrob AC, Murray CK, Lloyd B, Li P, Lu D, Miao Z, Aggarwal D, Carson ML, Gaskins L, and Tribble DR. Active Surveillance for Asymptomatic Colonization with Multidrug-Resistant Gram-Negative Bacilli among Injured Service Members - A Three-Year Evaluation. Medical Surveillance Monthly Report. 2013; 20(8):17-22.

Lloyd BA, Weintrob AC, Hinkle M, Fortuna G, Murray CK, Bradley W, Millar EV, Shaikh F, Vanderzant K, Gregg S, Lloyd G, Stevens J, Carson ML, Aggarwal D, and Tribble DR. Adherence to Published Antimicrobial Prophylaxis Guidelines for Wounded Service Members in the Ongoing Conflicts in Southwest Asia. Military Medicine. 2014; 179(3):324-328.

Akers KS, Mende K, Cheatle K, Zera W, Yu X, Beckius M, Aggarwal D, Li P, Sanchez C, Wenke JC, Weintrob AC, Tribble DR, Murray CK, and the IDCRP TIDOS Group. Biofilms and Persistent Wound Infections in United States Military Trauma Patients: A Case-Control Analysis. BMC Infectious Diseases. 2014; 14:190.

Rini EA, Weintrob AC, Tribble DR, Lloyd BA, Warkentien TE, Shaikh F, Li P, Aggarwal D, Carson ML, Murray CK and the IDCRP TIDOS Group.  Compliance with Antimalarial Chemoprophylaxis Recommendations for Wounded United States Military Personnel Admitted to a Military Treatment Facility. American Journal of Tropical Medicine and Hygiene. 2014; 90(6):1113-1116.

Rodriguez C, Weintrob AC, Shah J, Malone D, Dunne JR, Weisbrod AB, Lloyd BA, Warkentien T, Murray CK, Wilkins K, Shaikh F, Carson ML, Aggarwal D, Tribble DR and the IDCRP TIDOS Group. Risk Factors Associated with Invasive Fungal Infections in Combat Trauma. Surgical Infections. 2014; 15(5):521-526.

Lloyd BA, Weintrob AC, Rodriguez C, Dunne J, Weisbrod AB, Hinkle M, Warkentien T, Murray CK, Oh J, Millar EV, Shah J, Shaikh F, Gregg S, Lloyd G, Stevens J, Carson ML, Aggarwal D, Tribble DR and the IDCRP TIDOS Group. Effect of Early Screening for Invasive Fungal Infections in U.S. Service Members with Explosive Blast Injuries. Surgical Infections. 2014; 15(5):619-626.

Mende K, Beckius M, Zera WC, Yu X, Cheatle KA, Aggarwal D, Li P, Lloyd BA, Tribble DR, Weintrob AC, and Murray CK. Phenotypic and Genotypic Changes over Time and across Facilities of Serial Colonizing and Infecting Escherichia coli Isolates Recovered from Injured Service Members. Journal of Clinical Microbiology. 2014; 52(11):3869-3877.

Rodriguez C, Weintrob AC, Dunne JR, Weisbrod AB, Lloyd BA, Warkentien T, Malone D, Wells J, Murray CK, Bradley W, Shaikh F, Shah J, Carson ML, Aggarwal D, Tribble DR and the IDCRP TIDOS Group. Clinical Relevance of Mold Culture Positivity With and Without Recurrent Wound Necrosis Following Combat-Related Injuries. Journal of Trauma. 2014; 77(5):769-773.

Tribble DR and Rodriguez CJ. Combat-related Invasive Fungal Wound Infections. Current Fungal Infection Reports. 2014; 8(4):277-286.

Blyth DM, Mende K, Weintrob AC, Beckius ML, Zera WC, Bradley W, Lu D, Tribble DR, Murray CK, and the IDCRP TIDOS Group.  Resistance Patterns and Clinical Significance of Candida Colonization and Infections in Combat-Related Injured Patients from Iraq and AfghanistanOpen Forum Infectious Diseases. 2014; 1(3): doi: 10.1093/ofid/ofu109.

Weintrob AC, Weisbrod AB, Dunne JR, Rodriguez C, Malone D, Lloyd BA, Warkentien T, Wells J, Murray CK, Bradley W, Shaikh F, Shah J, Aggarwal D, Carson ML, Tribble DR and the IDCRP TIDOS Group. Combat Trauma-Associated Invasive Fungal Wound Infections: Epidemiology and Clinical Classification. Epidemiology and Infection.  2015; 143(1):214-224.

Yun HC, Weintrob AC, Conger NG, Li P, Lu D, Tribble DR, Murray CK and the IDCRP TIDOS Group.  Healthcare-Associated Pneumonia among U.S. Combat Casualties, 2009 to 2010. Military Medicine. 2015; 180(1):104-110.

Warkentien TE, Shaikh F, Weintrob AC, Rodriguez CJ, Murray CK, Lloyd BA, Ganesan A, Aggarwal D, Carson ML, and Tribble DR on behalf of the IDCRP TIDOS Group.  Impact of Mucorales and Other Invasive Molds on Clinical Outcomes of Polymicrobial Traumatic Wound Infections. Journal of Clinical Microbiology. 2015; 53(7): 2262-2270.

Tribble DR, Rodriguez CJ, Weintrob AC, Murray, CK, Aggarwal D, Shaikh F, Carson ML, Masuoka P, and the IDCRP TIDOS Group. Environmental Factors Related to Fungal Wound Contamination after Combat Trauma in Afghanistan, 2009-2011. Emerging Infectious Diseases. 2015; 21(10):1750-1760.

Blyth DM, Yun HC, Tribble DR, and Murray CK. Lessons of War: Combat-related Injury Infections during the Vietnam War and Operation Iraqi and Enduring Freedom. Journal of Trauma and Acute Care Surgery. 2015; 79(4 Suppl 2):S227-S235.