Medications for Pressure Ulcer Management
Pressure ulcer management relies primarily on non-pharmacologic interventions (dressings, debridement, pressure offloading, and nutritional support) rather than medications, with topical antimicrobials reserved only for infected wounds and systemic antibiotics used for advancing cellulitis, osteomyelitis, or sepsis. 1, 2
Nutritional Supplementation (Primary Pharmacologic Intervention)
The American College of Physicians recommends protein or amino acid supplementation to reduce wound size in patients with pressure ulcers, particularly those with nutritional deficiencies. 1, 2, 3
- This represents the strongest medication-based recommendation for pressure ulcer management, though the evidence quality is low 1
- Do not routinely supplement with vitamins (including vitamin C) or trace elements unless documented deficiency exists, as no benefit has been demonstrated 2
Topical Antimicrobials (For Infected Wounds Only)
Topical antimicrobials should only be used when infection is present, not routinely, to prevent bacterial resistance. 2, 4, 5
- Apply iodine preparations, medical-grade honey, or silver-containing dressings when infection is documented 2
- Consider topical antibiotics if there is no improvement in healing after 14 days of appropriate wound care 5
- Do not use povidone iodine routinely, as it may impair healing compared to non-antimicrobial dressings 2
- There is insufficient evidence that antiseptics or topical antibiotics improve healing more effectively than nonmedicated dressings 4
Systemic Antibiotics (For Complicated Infections)
Systemic antibiotics are indicated only for advancing cellulitis, osteomyelitis, or systemic infection—not for colonized or superficial wounds. 5, 2, 3
Antibiotic Selection for Infected Pressure Ulcers:
Pressure ulcer infections are typically polymicrobial (aerobes and anaerobes), requiring broad-spectrum coverage 6:
- Clindamycin: Excellent coverage against Staphylococcus aureus and anaerobes commonly found in pressure ulcers 6
- Trimethoprim-sulfamethoxazole: Bactericidal activity against common skin pathogens with no cross-reactivity with cephalosporins 6
- Fluoroquinolones (ciprofloxacin) + metronidazole: Broad-spectrum coverage against gram-positive, gram-negative bacteria, and anaerobes 6
- Carbapenems (ertapenem, imipenem, meropenem): Wide spectrum activity suitable for polymicrobial infections 6
- Piperacillin-tazobactam: Broad-spectrum including anti-Pseudomonas and anaerobic coverage 6
Treatment Algorithm:
- Obtain wound cultures before initiating antibiotics to guide targeted therapy 6
- Combine surgical debridement with antibiotic therapy for infected pressure ulcers 6
- Continue therapy for 10-14 days for most infections; longer courses may be needed for deep or complicated infections 6
- Monitor for clinical improvement within 48-72 hours of initiating therapy 6
Pain Management
Pain management should start with topical agents before progressing to systemic medications. 4
- When topical drugs fail to control pain, systemic medications should be considered 4
- Opioids should be used only if overall benefits outweigh risks 4
Medications NOT Recommended
- Pentoxifylline: Evidence supports its use for venous leg ulcers, not pressure ulcers 4
- Platelet-derived growth factor (becaplermin): Insufficient evidence for pressure ulcers 3
- Bioengineered skin products: Insufficient evidence for effectiveness 3
- Dextranomer paste: Inferior to other dressings 2
Critical Pitfalls to Avoid
- Do not culture wounds without clinical signs of infection, as this leads to inappropriate antibiotic use and resistance 2, 6
- Do not rely on inflammatory signs alone for infection diagnosis, as bacterial burden, virulence, and host immune status all affect presentation 2
- Avoid routine antimicrobial use in non-infected wounds to prevent bacterial resistance 4, 5
- Do not focus solely on medications—pressure offloading, debridement, and appropriate dressings remain the cornerstone of treatment 1, 3, 5