What are the recommendations for managing a decubitus ulcer in an admitted patient?

Management of Decubitus Ulcers in Admitted Patients

Surgical debridement of necrotic tissue combined with broad-spectrum antibiotics targeting polymicrobial organisms (Gram-positive, Gram-negative, and anaerobes) is the cornerstone of managing infected decubitus ulcers in hospitalized patients. 1

Immediate Assessment and Risk Stratification

Upon admission, evaluate the ulcer for:

• Depth of tissue involvement (superficial vs. deep tissue destruction extending to bone) 1
• Signs of infection: spreading cellulitis, purulent drainage, systemic signs (fever, tachycardia, hypotension, altered mental status) 1
• Location: most commonly ischium, sacrum, and greater trochanter 1
• Patient risk factors: frail elderly status, chronic comorbidities, immobility, malnutrition, poor circulation 2, 3

Surgical Intervention

Surgical debridement is necessary to remove necrotic tissue in all infected or deep pressure ulcers. 1 This is non-negotiable for achieving source control and preventing progression to systemic sepsis.

For extensive ulcers with bone involvement or large tissue defects:

• Consider musculocutaneous or fasciocutaneous flaps for definitive coverage 4
• These flaps are superior to cutaneous flaps alone for long-standing pressure sores 4

Antibiotic Therapy

Administer broad-spectrum antibiotics for severe pressure ulcer infections, including those with spreading cellulitis or systemic signs of infection. 1

The antibiotic regimen must cover:

• Gram-positive organisms: S. aureus, Enterococcus spp. 1
• Gram-negative organisms: Proteus mirabilis, E. coli, Pseudomonas spp. 1
• Anaerobes: Peptococcus spp., Bacteroides fragilis, Clostridium perfringens 1

MRSA Coverage Decision Algorithm

Add MRSA-directed antibiotics when: 1

• Local epidemiology shows >20% MRSA in invasive hospital isolates
• High community MRSA circulation
• Patient has specific MRSA risk factors (recent hospitalization, healthcare exposure, injection drug use)
• Severe systemic infection requiring ICU admission

Microbiological Sampling

Collect samples for bacterial AND fungal cultures from all surgical debridements before initiating antibiotics. 1 Adjust therapy based on culture results, as polymicrobial infections are the rule rather than the exception. 1

Pressure Relief and Wound Care

Encourage active movement and provide passive pressure relief through frequent position changes as the most beneficial prevention and treatment strategy. 3 This is more important than any topical therapy.

Specific measures include:

• Pressure-reducing surfaces and mattresses 3
• Repositioning every 2 hours for immobile patients 2
• Avoid prolonged pressure over bony prominences 5
• Address friction and shear forces 2

Addressing Underlying Risk Factors

Treat modifiable risk factors aggressively: 3

• Malnutrition: nutritional supplementation and consultation
• Poor circulation/hypoperfusion: optimize hemodynamics and treat underlying vascular disease
• Pain: adequate analgesia to facilitate movement
• Underlying diseases impairing mobility: physical therapy, treatment of neurological conditions

Vascular Assessment

Perform vascular assessment if the ulcer is on a lower extremity, as up to 50% of leg ulcers have arterial involvement. 6 Measure ankle-brachial index (ABI) and pedal Doppler waveforms to detect peripheral artery disease, which significantly increases risk for non-healing and limb loss. 6

Critical Pitfalls to Avoid

• Do not rely on topical wound care alone without addressing infection through debridement and systemic antibiotics 1
• Do not delay surgical debridement in infected ulcers, as this leads to systemic sepsis and increased mortality 1
• Do not use narrow-spectrum antibiotics for infected pressure ulcers, as these infections are invariably polymicrobial 1
• Do not forget to assess and treat underlying systemic factors (nutrition, circulation, mobility) that perpetuate ulcer formation 3
• Do not assume all decubitus ulcers are preventable or curable, as poor circulation and cognitive impairment can make prophylaxis difficult 3

Documentation and Reassessment

Repeatedly reassess and document: 3

• Feasibility and implementation of pressure-relief measures
• Efficacy of current treatment strategy
• Changes in ulcer characteristics (size, depth, infection signs)
• Patient's overall clinical trajectory and comorbidity management