What is the treatment for an infected ulcerated wound?

Treatment of Infected Ulcerated Wounds

All infected ulcerated wounds require antibiotic therapy combined with aggressive wound care, including sharp debridement, appropriate dressings for moist wound healing, and pressure off-loading when applicable. 1

Initial Assessment and Culture Collection

Before initiating treatment, obtain proper wound cultures to guide antibiotic selection: 1

• Cleanse and debride the wound first, then collect specimens from deep tissue using curettage (scraping with sterile scalpel or dermal curette) or tissue biopsy from the ulcer base 1
• Aspirate any purulent secretions with sterile needle and syringe 1
• Avoid swab specimens - they provide less accurate results and identify colonizing rather than pathogenic organisms 1
• Send specimens promptly for aerobic and anaerobic culture before starting antibiotics 1

Exception: Mild infections in patients without recent antibiotic exposure and low MRSA risk may not require cultures, as these are predictably caused by staphylococci and streptococci. 1

Antibiotic Therapy Duration

The duration depends on infection severity and tissue involvement: 1

• Mild to moderate soft tissue infections: 1-2 weeks is usually effective 1
• Severe soft tissue infections: 3 weeks is typically sufficient 1
• Osteomyelitis without bone resection: 6 weeks of antibiotics 1
• Osteomyelitis with complete bone resection: No more than 1 week of antibiotics 1

Stop antibiotics when signs and symptoms of infection resolve, even if the wound has not completely healed - antibiotics treat infection, not wounds. 1

Sharp Debridement (Essential Component)

Debridement removes necrotic tissue, biofilm, and bacterial reservoirs that impede healing: 1

• Perform sharp debridement with scalpel, scissors, or tissue nippers as the preferred method over hydrotherapy or topical debriding agents 1
• Repeat debridement as often as needed if nonviable tissue continues to form 1
• Most neuropathic foot wounds can be debrided at bedside without anesthesia 1
• Do not delay debridement while awaiting revascularization in ischemic limbs 1

Alternative debridement methods include autolytic dressings and maggot therapy for carefully selected necrotic infected wounds, though evidence is limited. 1

Wound Dressing Selection

Choose dressings based on wound characteristics to maintain moist wound healing: 1

• Dry or necrotic wounds: Continuously moistened saline gauze or hydrogels 1
• Exudative wounds: Alginates (also hemostatic if bleeding) or foams 1
• Moderate exudate with autolysis needed: Hydrocolloids 1
• Films: For moistening dry wounds (occlusive/semi-occlusive) 1

Change dressings at least daily to allow wound inspection and apply clean coverings. 1 Do not use topical antimicrobials for most wounds - systemic antibiotics are preferred. 1

Pressure Off-Loading (Critical for Diabetic Foot Ulcers)

Relieving pressure is vital for wound healing in weight-bearing areas: 1

• Total contact cast is the gold standard for neuropathic ulcers, redistributing pressure across the entire weight-bearing surface 1
• Use with caution in severe peripheral arterial disease or active infection, as it prevents wound visualization 1
• Removable off-loading devices are alternatives, but patients often remove them at home 1
• Choose devices that permit easy wound inspection for infected wounds 1

Vascular Assessment and Revascularization

For ischemic infected wounds, early vascular intervention is critical: 1

• Perform revascularization within 1-2 days of recognizing infection in severely ischemic feet, rather than prolonged ineffective antibiotic therapy 1
• Patients with ankle-brachial index 0.4-0.9 (noncritical ischemia) may be treated without vascular procedures in some cases 1
• Both endovascular intervention and distal bypass procedures are effective for severe vascular disease 1

Adjunctive Therapies (Limited Evidence)

No adjunctive therapy has been proven to improve infection resolution, but may be considered for slow-healing wounds: 1

• Hyperbaric oxygen therapy: Strong recommendation with moderate evidence for wound healing (not infection) 1
• Granulocyte colony-stimulating factor (G-CSF): May reduce need for operative procedures but does not accelerate infection resolution 1
• Negative pressure wound therapy: Weak recommendation with low evidence; some benefit shown in post-surgical wounds 1
• Growth factors, bioengineered skin equivalents: Weak to moderate evidence 1

When to Reassess or Refer

If the wound fails to heal despite appropriate management, reevaluate for: 1, 2

• Unidentified or untreated ischemia requiring vascular consultation 1, 2
• Undiagnosed osteomyelitis that has not responded to treatment 1, 2
• Undrained abscess or unidentified necrotic tissue/bone 1, 2
• Malignancy (melanoma, Kaposi sarcoma) masquerading as ulcer - obtain biopsy of atypical wounds 1, 2
• Inadequate debridement or off-loading 1, 2
• Patient non-adherence to wound care regimen 1

Consult a wound specialist if no healing progress after 6 weeks of optimal management or if stage III-IV ulcers require surgical debridement/reconstruction. 2

Common Pitfalls to Avoid

• Do not culture uninfected wounds - this identifies colonizers, not pathogens 1
• Do not use swab cultures from inadequately debrided wounds 1
• Do not delay revascularization in severely ischemic infected limbs 1
• Do not continue antibiotics until wound healing - stop when infection resolves 1
• Do not use total contact casts when you cannot visualize the wound in active infection 1