How should I treat an obese patient with a fungal infection and a pressure sore under the abdominal fold?

Treatment of Fungal Infection and Pressure Sore in Obese Patient with Abdominal Fold Involvement

For the fungal infection (likely intertriginous candidiasis), apply topical azole antifungals (clotrimazole, miconazole, or ketoconazole cream) twice daily for 2-4 weeks, and for the pressure ulcer, perform surgical debridement of necrotic tissue combined with broad-spectrum antibiotics covering polymicrobial organisms if signs of infection are present. 1, 2

Fungal Infection Management

Primary Topical Therapy

• Apply topical azole antifungals (clotrimazole, miconazole, or ketoconazole cream) to the affected skin fold twice daily for 2-4 weeks, as this extended duration is associated with lower recurrence rates in skin fold candidiasis 2
• Ensure the area is kept dry and clean with soap and water, then thoroughly dried before application 1
• Consider applying a barrier cream containing zinc oxide to protect surrounding skin from moisture and prevent extension of infection 1

Systemic Antifungal Therapy

• For extensive or treatment-refractory fungal infection, add oral fluconazole 150-200 mg as a single dose or repeated every 72 hours for 2-3 doses 2, 3
• This systemic approach is particularly indicated when topical therapy alone has failed or when complicated by diabetes or other predisposing factors 2
• Obesity itself increases susceptibility to Candida infections, with obese patients showing higher prevalence of Candida albicans colonization 4, 5

Recurrent Infection Prevention

• If this represents recurrent infection (multiple episodes within 6 months), initiate suppressive therapy with fluconazole 150 mg weekly for 6 months after initial clearance 2
• Address underlying risk factors: optimize diabetes control if present, ensure adequate air circulation to the fold, and avoid occlusive clothing 2

Pressure Ulcer Management

Surgical Debridement

• Surgical debridement is necessary to remove all necrotic tissue from the pressure ulcer, as this is essential for infection control and healing 1
• The pressure ulcer likely developed from prolonged compression of soft tissue between the abdominal fold and external surface 1

Antibiotic Therapy for Infected Pressure Ulcer

• Administer broad-spectrum antibiotics covering both aerobic and anaerobic organisms if the ulcer shows signs of infection (spreading cellulitis, purulent drainage, systemic signs) 1
• Pressure ulcer infections are typically polymicrobial, including S. aureus, Enterococcus spp., Proteus mirabilis, E. coli, Pseudomonas spp., Peptococcus spp., Bacteroides fragilis, and Clostridium perfringens 1
• Collect wound cultures before initiating antibiotics to guide subsequent therapy adjustment 1

Antifungal Considerations for Pressure Ulcer

• Do not routinely add empiric antifungal therapy for the pressure ulcer unless the patient is critically ill, severely immunocompromised, or has documented fungal organisms in wound cultures 1
• The evidence does not support routine empiric antifungal therapy in community-acquired skin and soft tissue infections, even in obese patients 1
• However, if fungal organisms are isolated from wound cultures in a frail elderly patient with comorbidities, consider adding antifungal therapy 1

Critical Management Considerations

Obesity-Specific Factors

• Obesity increases risk of both fungal skin infections and impaired wound healing through multiple mechanisms including altered skin barrier function, increased moisture in skin folds, and immune dysfunction 6, 4
• Obese patients have different inflammatory responses with lower IL-6 concentrations, which may affect healing 7
• Obesity alone does not require longer duration of antimicrobial therapy, but adequate source control is essential 1

Wound Care Essentials

• Ensure proper tension relief from the abdominal fold to prevent continued pressure on the ulcer 1
• Use foam dressings rather than gauze to reduce skin maceration and lift drainage away from surrounding skin 1
• Monitor for overgranulation tissue, which is common and may require topical antimicrobial agents or silver dressings 1

Duration of Therapy

• Continue antibiotic therapy for 3-4 days after adequate source control in the pressure ulcer, as short-course therapy is effective even in complicated infections 1
• Continue topical antifungal therapy for the full 2-4 weeks to decrease likelihood of recurrence 2
• Treatment should continue until clinical resolution of both conditions 1, 2

Common Pitfalls to Avoid

• Do not use weight-based dosing for vasopressors or fluids per kilogram in obese patients, as they require less per kilogram than normal-weight patients 7
• Do not assume fungal growth in wound cultures automatically requires antifungal therapy unless the patient is critically ill or immunocompromised 1
• Do not neglect addressing underlying metabolic conditions (diabetes, immunosuppression) that predispose to both fungal infections and poor wound healing 2, 4
• Avoid occlusive dressings or clothing that trap moisture in the abdominal fold, as this promotes fungal overgrowth 2