What is the management approach for infected wounds of calciphylaxis?

Management of Infected Wounds in Calciphylaxis

Infected calciphylaxis wounds require immediate aggressive surgical debridement combined with broad-spectrum antibiotics, rigorous wound care, and multidisciplinary management to prevent the 60-80% mortality associated with sepsis and organ failure in this condition. 1, 2

Immediate Surgical Intervention

Perform aggressive surgical debridement immediately to remove all necrotic tissue, eschar, and infected material—this is the cornerstone of management and should not be delayed. 1 Sharp debridement using scalpel, scissors, or tissue nippers is the preferred method, as it provides definitive removal of devitalized tissue that serves as a reservoir for pathogens. 3 Multiple staged procedures may be necessary given the extensive nature of calciphylaxis wounds. 3

• Do not delay debridement while awaiting other interventions—immediate removal of necrotic infected material is critical even if revascularization or other procedures are planned. 3
• Debridement should be performed by experienced clinicians, ideally vascular surgeons familiar with calciphylaxis, as part of the multidisciplinary team. 1

Antibiotic Therapy

Initiate broad-spectrum parenteral antibiotics immediately for all infected calciphylaxis wounds, as these patients are at extremely high risk for sepsis and death. 3

• Obtain deep tissue cultures via biopsy or curettage from the debrided wound base before starting antibiotics when possible, but do not delay treatment if the patient is systemically ill. [3, @18@]
• Avoid superficial swabs of undebrided wounds as they provide inaccurate results. [3, @18@]
• Empiric coverage should target aerobic gram-positive cocci, gram-negative organisms, and anaerobes given the polymicrobial nature of these chronic, necrotic wounds. 3
• Consider MRSA coverage if the patient has prior MRSA history, high local prevalence, or severe systemic infection. 3
• Continue antibiotics until clinical resolution of infection, not necessarily until complete wound healing—typically 2-4 weeks for severe soft tissue infections depending on adequacy of debridement. 3

Rigorous Wound Care Protocol

Implement meticulous daily wound care as infection prevention and management are critical to survival in calciphylaxis. 1, 2

• Dress wounds to maintain a moist healing environment while allowing daily inspection. 3
• Avoid topical antibiotics—there is insufficient evidence they improve outcomes in infected wounds. 3
• Perform frequent serial debridements as necrotic tissue accumulates—often more frequently than weekly given the progressive nature of calciphylaxis. 1

Vascular Assessment and Revascularization

Evaluate arterial perfusion urgently as some calciphylaxis patients may have concurrent peripheral arterial disease requiring intervention. 1

• Obtain ankle-brachial index, toe pressures, and consider arteriography if pulses are diminished or absent. 1
• If significant arterial stenosis is identified, perform revascularization within 1-2 days rather than relying on prolonged antibiotic therapy alone for severely infected ischemic wounds. 3
• Note that calciphylaxis involves small vessel disease with medial calcification, so large vessel revascularization may provide limited benefit, but should be pursued when indicated. 1, 4

Multidisciplinary Management

Assemble a multidisciplinary team immediately including nephrology, endocrine surgery, vascular surgery, wound care specialists, infectious disease, and pain management. 1, 4, 5

• Address underlying hyperparathyroidism with subtotal or total parathyroidectomy by an experienced endocrine surgeon, as this is essential for wound healing. 1
• Optimize dialysis regimens and correct calcium-phosphate metabolism abnormalities in collaboration with nephrology. 1, 5
• Consider skin grafting after infection control and adequate debridement by plastic surgery when primary closure is not feasible. 1

Critical Monitoring

Follow patients with infected calciphylaxis wounds daily if hospitalized or every 2-5 days as outpatients initially to ensure treatment efficacy. 3

• Monitor for progression of infection, systemic signs of sepsis, and adequacy of debridement. 3
• Hospitalize patients with severe infection, systemic toxicity, extensive necrosis, or inability to comply with outpatient management. 3
• Watch for complications including deep abscess formation, osteomyelitis, septic arthritis, and necrotizing fasciitis which require urgent surgical consultation. 3

Common Pitfalls to Avoid

• Never delay debridement in favor of medical management alone—inadequate surgical intervention is associated with poor outcomes. 1
• Do not underestimate infection severity—calciphylaxis wounds have 60-80% mortality primarily from sepsis. 2
• Avoid inadequate antibiotic coverage—these are polymicrobial infections requiring broad-spectrum therapy. 3
• Do not manage these patients in isolation—single-specialty management is inadequate for this complex condition. 4, 5