In an elderly patient with a recent history of rhabdomyolysis after a fall, who is now doing okay with therapy but has a stage‑2 pressure ulcer over the coccyx and persistent leukocytosis, what is the appropriate management?

Evaluate for Infected Pressure Ulcer and Rule Out Osteomyelitis

In this elderly patient with persistent leukocytosis (WBC 13.3) and a stage 2 coccyx pressure ulcer following recent rhabdomyolysis, you need to determine if the pressure ulcer is infected and assess for underlying osteomyelitis, as infected pressure ulcers are a common source of persistent leukocytosis in this population.

Immediate Clinical Assessment

First, examine the pressure ulcer for signs of infection beyond simple colonization:

• Look for purulent drainage, persistent exudate, or poor healing despite appropriate wound care
• Check for surrounding cellulitis, warmth, or advancing erythema
• Assess for systemic signs: fever, worsening functional status, or hemodynamic instability

The leukocytosis of 13.3 is modest but persistent, which raises concern for an infectious source. In elderly patients with pressure ulcers, skin and soft tissue infections are the third most common infection in long-term care settings 1.

Diagnostic Approach

For the Pressure Ulcer:

Do NOT obtain surface swab cultures - these are not indicated and will only show colonization 1. Surface cultures are meaningless for pressure ulcers.

If the ulcer shows poor healing or persistent purulent drainage:

• Obtain deep tissue specimens for culture during surgical debridement or biopsy 1
• This is the only reliable way to identify true pathogens versus colonizers

Assess for osteomyelitis if:

• Bone is exposed or palpable with a probe
• The ulcer is not healing despite appropriate care
• There are systemic signs of infection

If osteomyelitis is suspected, MRI is the most sensitive (98%) and specific (89%) imaging modality 1. Bone biopsy provides definitive diagnosis and guides antimicrobial therapy 1.

Additional Workup:

• Blood cultures if there are systemic signs (fever, hypotension, altered mental status)
• Repeat CBC to trend leukocytosis
• Basic metabolic panel to assess renal function (important given recent rhabdomyolysis history)
• Consider inflammatory markers (ESR, CRP) if osteomyelitis is suspected

Management Strategy

If No Signs of Infection:

Continue optimized wound care:

• Use hydrocolloid dressings over gauze - they are superior for reducing wound size 2
• Ensure pressure offloading with appropriate support surfaces
• Optimize nutrition with protein supplementation - this improves wound healing rates 2
• Monitor the leukocytosis; it may be residual from the recent rhabdomyolysis or another non-infectious cause

If Infection is Present Without Systemic Signs:

• Debride necrotic tissue if present
• Consider topical antimicrobials if no improvement after 14 days of appropriate wound care 3
• Continue aggressive wound care with appropriate dressings
• Maintain strict pressure offloading

If Advancing Cellulitis, Sepsis, or Osteomyelitis:

Initiate systemic antibiotics immediately 4, 3:

• Cover polymicrobial flora: gram-negative bacilli (E. coli, Proteus, Pseudomonas), gram-positive cocci (Staph, Strep), and anaerobes 1
• Empiric broad-spectrum coverage pending culture results
• Urgent sharp debridement is indicated for advancing cellulitis or sepsis 3

Critical Pitfalls to Avoid

1. Don't rely on surface swab cultures - they will mislead you with colonizing organisms
2. Don't assume the leukocytosis is from the pressure ulcer alone - elderly patients often have multiple potential sources
3. Don't miss osteomyelitis - exposed bone with positive surface cultures does NOT confirm osteomyelitis; you need imaging or biopsy 1
4. Remember the rhabdomyolysis context - this patient had prolonged immobilization after a fall, which is a major risk factor for both rhabdomyolysis and pressure ulcer development in elderly patients 5, 6

Special Considerations for This Patient

Given the recent rhabdomyolysis from a fall, this patient likely had:

• Prolonged immobilization (the primary cause of rhabdomyolysis in elderly patients) 6
• Increased vulnerability to pressure ulcer development during the acute illness
• Potential ongoing mobility limitations affecting healing

Monitor renal function closely - the combination of recent rhabdomyolysis and potential infection/sepsis puts this patient at higher risk for acute kidney injury 5.

The stage 2 ulcer is relatively superficial (partial-thickness skin loss), so if there are no signs of infection and the patient is otherwise stable, the leukocytosis may warrant investigation for other sources (urinary tract, respiratory, residual inflammation from rhabdomyolysis).