What is the treatment for heel wound infections?

Treatment of Heel Wound Infections

Heel wound infections require a combined approach of aggressive surgical debridement, appropriate antibiotic therapy targeting identified pathogens, and meticulous wound care with pressure off-loading—antibiotics treat infection, not wounds, and should be discontinued once infection resolves even if the wound remains open. 1, 2

Initial Assessment and Debridement

Sharp surgical debridement is the cornerstone of treatment and should not be delayed. 1

• Perform immediate sharp debridement using scalpel, scissors, or tissue nippers to remove all necrotic tissue, callus, and devitalized material 1
• Sharp debridement is superior to hydrotherapy or topical debriding agents, which are less definitive and require prolonged applications 1
• Use a sterile metal probe to assess wound depth, detect bone involvement (which has a characteristic stony feel when touched), and identify abscesses or foreign bodies 1
• Debridement removes the bacterial reservoir and biofilm, which is critical for infection control 1, 3
• Multiple staged debridement procedures may be necessary for optimal outcomes 1

Vascular Assessment

Evaluate arterial perfusion immediately, as ischemic heel wounds may require early revascularization (within 1-2 days) rather than prolonged antibiotic therapy alone. 1

• Measure ankle-brachial index (ABI): values <0.90 indicate peripheral vascular disease; <0.50 suggests critical ischemia that will impair healing 1
• Check ankle blood pressure (should be >50 mm Hg) and toe pressure (should be >30 mm Hg) 1
• For severely infected ischemic heel wounds, perform revascularization within 1-2 days rather than delaying for prolonged antibiotic therapy 1

Antibiotic Selection and Duration

Select empirical antibiotics based on infection severity and local resistance patterns, then narrow therapy based on culture results. 1

Empirical Therapy:

• Mild-to-moderate infections: Coverage for aerobic gram-positive cocci (S. aureus, Streptococcus) is usually sufficient in patients without recent antibiotic exposure 1
• Severe infections: Broad-spectrum empirical therapy is required pending culture results, with consideration for MRSA coverage based on local prevalence 1
• Obtain deep tissue specimens or bone biopsy for culture before starting antibiotics when possible—avoid superficial swabs as they yield contaminants 1

Definitive Therapy Duration:

• Mild infections: 1-2 weeks, occasionally extending to 3-4 weeks total 1
• Moderate-to-severe soft tissue infections: 2-4 weeks depending on adequacy of debridement and wound vascularity 1
• Osteomyelitis with complete bone resection: ≤1 week of antibiotics post-operatively 1
• Osteomyelitis without bone resection: 6 weeks of antibiotic therapy 1
• Stop antibiotics when signs of infection resolve, not when the wound heals—antibiotics treat infection, not wounds 1, 2

Specific Agents:

• Linezolid 600 mg every 12 hours (IV or oral) is effective for MRSA and complicated skin infections including diabetic foot infections, with cure rates of 79-83% 4
• Highly bioavailable oral antibiotics can be used for most mild and many moderate infections, including some osteomyelitis cases 1

Wound Care and Off-Loading

Pressure off-loading is absolutely critical and non-negotiable for heel wound healing. 1

• Remove all pressure from the heel wound using appropriate off-loading devices that permit daily wound inspection 1
• Dress wounds to maintain a moist healing environment and allow daily inspection 1
• No specific dressing type has proven superior—select based on exudate level (absorptive for heavy drainage, moisture-adding for dry wounds) 1
• Change dressings at least daily to apply clean coverings and examine for infection progression 1

Surgical Considerations

Seek immediate surgical consultation for deep abscesses, extensive bone involvement, crepitus, substantial necrosis, gangrene, or necrotizing fasciitis. 1

• Stage IV heel pressure ulcers (involving muscle, tendon, or bone) often require surgical intervention beyond simple debridement for successful healing 5
• Options include partial or total calcanectomy, free tissue flaps, or amputation for failed interventions or high-risk patients 5
• For osteomyelitis, consider surgical resection of infected bone combined with short-course antibiotics rather than prolonged medical therapy alone 1

Adjunctive Therapies

Hyperbaric oxygen therapy may reduce major amputation risk in diabetic heel ulcers, but should not replace proper debridement and conventional therapy. 1

• Hyperbaric oxygen significantly reduced major amputation risk in diabetic foot ulcers per Cochrane review 1
• Granulocyte colony-stimulating factors (G-CSF) may reduce need for operative procedures but do not accelerate infection resolution 1
• Negative pressure wound therapy with irrigation may lower bacterial burden and prevent biofilm re-establishment after debridement 1
• None of these adjunctive therapies should substitute for adequate surgical debridement and appropriate antibiotics 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for uninfected heel ulcers—there is no evidence they prevent infection or hasten healing 2
• Do not use topical antimicrobials or specific dressings with the expectation of preventing infection or improving outcomes—the evidence does not support this 1
• Do not delay revascularization in ischemic infected heels in favor of prolonged antibiotic therapy, as this approach is ineffective 1
• Do not continue antibiotics until wound closure—stop when infection resolves, as prolonged unnecessary antibiotics promote resistance 1, 2