Management of Pressure Injuries (Bedsores): A DNB Teaching Module

PowerPoint Structure for 1-Hour Session

Slide 1-3: Opening & Epidemiology (5 minutes)

Title: Pressure Injuries - A Preventable Crisis

Key Statistics:
- 2.5 million hospital-acquired pressure injuries (HAPIs) annually in the United States 1
- National HAPI rate: 3.5% of observed patients 1
- Increase mortality, length of stay, and healthcare costs significantly 2

MCQ #1 (Difficult): A 68-year-old paraplegic patient develops a sacral pressure injury with exposed bone. Bone biopsy shows polymorphonuclear infiltration. Blood cultures grow Peptostreptococcus and Bacteroides. No surgery is planned. What is the appropriate antibiotic duration?

A) 5 days
B) 10-14 days
C) 6 weeks
D) No systemic antibiotics

Answer: D - 3 explicitly states that pelvic osteomyelitis without soft tissue infection and no plans for debridement requires NO systemic antibiotics.

Slide 4-8: Classification & Risk Assessment (8 minutes)

Staging System (National Pressure Injury Advisory Panel):

Stage 1: Non-blanchable erythema of intact skin
Stage 2: Partial-thickness skin loss with exposed dermis
Stage 3: Full-thickness skin loss, subcutaneous fat visible
Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle
Unstageable: Obscured by slough/eschar
Deep Tissue Pressure Injury: Persistent non-blanchable deep red/purple discoloration

Critical Risk Factors:

Intrinsic: Spinal cord injury, sensory loss, malnutrition, incontinence, obesity 4
Extrinsic: Prolonged pressure, friction, shear forces, moisture 5

MCQ #2 (Difficult): Which anatomical site has the LOWEST recurrence rate after surgical flap reconstruction?

A) Ischial pressure ulcers
B) Sacral pressure ulcers
C) Trochanteric ulcers
D) Equal recurrence rates

Answer: B - 6 reports sacral ulcers have lower recurrence rates than ischial ulcers after surgery.

Slide 9-15: Antibiotic Management - The Core Algorithm (15 minutes)

CRITICAL DECISION TREE FOR ANTIBIOTIC USE:

Step 1: Determine Clinical Scenario

A. Skin/Soft Tissue Infection WITHOUT Abscess:

Duration: 5 days 3
Extend only if slow clinical improvement
Empiric coverage: Must cover MRSA (consider local epidemiology - up to 85% MRSA in some centers 3)
Vancomycin or linezolid as first-line

B. Cutaneous Abscess:

Duration: 5-10 days AFTER drainage 3
Drainage is mandatory; antibiotics are adjunctive
Cover MRSA + gram-negatives if extensive

C. Pyomyositis:

Duration: 14-21 days with abscess drainage 3
Requires imaging confirmation (MRI preferred)

D. Stage IV Pressure Injury WITHOUT Infection:

NO SYSTEMIC ANTIBIOTICS 3
This is the most common pitfall - exposed bone ≠ infection

E. Pelvic Osteomyelitis WITHOUT Soft Tissue Infection, NO Surgery Planned:

NO SYSTEMIC ANTIBIOTICS 3
Bone histopathology is gold standard (polymorphonuclear or mononuclear infiltration)
Exposed bone alone does NOT indicate osteomyelitis (pressure-related changes occur in all Stage IV injuries 3)

F. Pelvic Osteomyelitis AFTER Surgical Debridement + Flap Reconstruction:

Duration: 6 weeks 3
Shorter duration (2-4 weeks) may be appropriate if:
- Infection limited to cortical bone only
- Complete debridement achieved
- However, high-quality data lacking 3
Oral antibiotics may be adequate in selected patients 3

Slide 16-18: Microbiology & Resistance Patterns (7 minutes)

Typical Organisms in Pressure Injuries:

Most Common (in order):

Staphylococcus aureus (77.1% in bone biopsies, 18% overall) 3
- Up to 85% MRSA in some centers 3
Peptostreptococcus spp. (48.6%) 3
Bacteroides spp. (40%) 3
Pseudomonas aeruginosa (8%)
Enterococcus spp. (8%)

70.4% are polymicrobial 3

Resistance Concerns:

21.6% of gram-negatives are multidrug-resistant (predominantly P. aeruginosa and Acinetobacter) 3
Always consider local antibiogram when selecting empiric therapy

Culture Technique Matters:

Levine swabs and superficial cultures often isolate commensals 3
Intraoperative excisional bone biopsy during debridement is preferred 3
Interpret cultures within clinical context: patient immunology, wound chronicity, response to therapy 3

MCQ #3 (Difficult): A patient with Stage IV sacral pressure injury undergoes flap reconstruction. Bone culture grows MRSA and Bacteroides fragilis. Surgery was complete with good debridement. What is the optimal antibiotic regimen?

A) IV vancomycin + metronidazole for 6 weeks
B) IV vancomycin + metronidazole for 2 weeks, then oral for 4 weeks
C) Oral linezolid + metronidazole for 6 weeks
D) IV vancomycin + metronidazole for 12 weeks

Answer: C - 3 states oral antibiotics may be adequate for osteomyelitis treatment in selected patients. With complete debridement and good source control, oral therapy for 6 weeks is appropriate.

Slide 19-22: De-escalation Strategy (7 minutes)

Antibiotic De-escalation Protocol:

1. Initial Empiric Therapy (Day 0-2):

Broad-spectrum: Vancomycin + piperacillin-tazobactam OR carbapenem
Cover MRSA + gram-negatives + anaerobes
Adjust based on local resistance patterns

2. Culture-Directed Therapy (Day 3-5):

Narrow to targeted agents based on:
- Culture results (bone biopsy preferred)
- Susceptibility patterns
- Clinical response (fever resolution, wound improvement)

3. Oral Transition (When Appropriate):

Criteria for oral switch:
- Hemodynamically stable
- Afebrile >24 hours
- Improving wound appearance
- Adequate oral bioavailability agents available
- Good GI absorption

Oral Options with Excellent Bone Penetration:

Linezolid (MRSA)
Fluoroquinolones (gram-negatives, but resistance increasing)
Metronidazole (anaerobes)
Clindamycin (MRSA if susceptible, anaerobes)
Trimethoprim-sulfamethoxazole (MRSA)

Common Pitfall: Prolonging IV antibiotics as "bridge to surgery" when surgery is delayed - NO BENEFIT 3

Slide 23-26: Surgical Input & Multidisciplinary Approach (8 minutes)

When to Consult Surgery:

Absolute Indications:

Stage IV with pelvic osteomyelitis requiring debridement
Large abscesses requiring drainage
Non-healing wounds despite optimal medical management
Fistula formation

Surgical Options:

Debridement of necrotic tissue and infected bone
Flap reconstruction (muscle or fasciocutaneous)
1-stage vs 2-stage procedures

Surgical Outcomes:

Dehiscence is most common complication 6
Reoperation rate: 12-24% due to recurrence or flap failure 6
Spinal cord injury patients have HIGHER recurrence rates than other populations 6
Complication rate for skin flap surgeries: 21% 6

Multidisciplinary Team Components:

Medicine: Risk assessment, medical optimization
Surgery: Debridement, flap reconstruction
Infectious Disease: Antibiotic selection, duration, resistance management
Nutrition: Protein supplementation (improves healing 6)
Wound Care Nurses: Dressing selection, monitoring
Physical Therapy: Repositioning protocols
Case Management: Discharge planning, equipment needs

MCQ #4 (Difficult): A 45-year-old with T6 spinal cord injury undergoes flap closure for ischial pressure injury with osteomyelitis. Compared to a non-SCI patient, what is this patient's risk profile?

A) Lower recurrence rate, same complication rate
B) Same recurrence rate, higher complication rate
C) Higher recurrence rate, same complication rate
D) Higher recurrence rate, higher complication rate

Answer: C - 6 specifically states SCI patients have higher recurrence rates after surgical flap closure compared to other pressure injury patients.

Slide 27-32: Prevention Strategies (Inpatient & Outpatient) (8 minutes)

Evidence-Based Prevention Bundle:

1. Pressure Redistribution (91.9-95.4% adherence 7):

Air-fluidized beds reduce ulcer size (moderate-quality evidence 6)
Other support surfaces show no difference 6
Pressure-redistributing mattresses for high-risk patients

2. Repositioning (78.6-90.4% adherence - LOWEST 7):

Every 2 hours for bedridden patients
Every 15 minutes for wheelchair users (or pressure relief lifts)
Document position changes
This is the most improvable intervention 7

3. Moisture Management (91.9-95.4% adherence 7):

Incontinence care protocols
Barrier creams
Absorbent pads (change frequently)

4. Nutritional Optimization (78.6-90.4% adherence - LOWEST 7):

Protein-containing supplements improve wound healing (moderate-quality evidence 6)
Vitamin C supplementation does NOT improve healing 6
Target: 1.25-1.5 g/kg/day protein for healing wounds
This is the most improvable intervention 7

5. Skin Assessment:

Within 24 hours of admission (should be 100% 1)
Daily for high-risk patients
Use structured tools (Braden Scale)

Outpatient Prevention:

Education on self-inspection (mirrors for wheelchair users)
Pressure mapping for wheelchair cushions
Home health nursing for high-risk patients
Caregiver training on repositioning

Slide 33-36: Wound Management & Dressing Selection (6 minutes)

Debridement Principles:

Remove devitalized tissue and biofilm 4
Sharp debridement for eschar/slough
Enzymatic debridement if surgery contraindicated
Autolytic debridement for stable patients

Dressing Selection Algorithm:

Stage 1-2 (Superficial):

Hydrocolloid dressings reduce ulcer size vs gauze (low-quality evidence 6)
Transparent films for Stage 1
Foam dressings for Stage 2 with exudate

Stage 3-4 (Deep):

Foam dressings for moderate exudate
Alginate/hydrofiber for heavy exudate
Avoid dextranomer paste (inferior to other dressings 6)
Consider negative-pressure wound therapy (mixed evidence 6)

Infection Present:

Silver-impregnated dressings
Cadexomer iodine
Avoid occlusive dressings

Adjunctive Therapies:

Electrical stimulation accelerates healing (moderate-quality evidence 6)
Platelet-derived growth factor (PDGF) improves healing (low-quality evidence 6)
Ultrasound, laser, light therapy: no difference or mixed findings 6

Slide 37-40: Monitoring for Complications (4 minutes)

Monitor ALL Pressure Injuries For:

1. Local Infection Signs:

Increased erythema, warmth, purulence
Foul odor
Increased pain (if sensation intact)
Delayed healing

2. Biofilm Formation:

Slimy, adherent material
Requires mechanical debridement
Antibiotics alone insufficient

3. Osteomyelitis (Stage IV):

Prevalence: 17-58% in Stage IV injuries 3
Exposed bone alone does NOT diagnose osteomyelitis 3
Bone histopathology is gold standard 3
MRI shows bone marrow edema (but also present in non-infected Stage IV 3)
Probe-to-bone test has limited utility

4. Systemic Infection:

Bacteremia (anaerobes isolated twice as often as aerobes 3)
Sepsis
Multifocal bone involvement with new draining tracts 3

Slide 41-43: Antibiotic Resistance - The Growing Threat (3 minutes)

Key Resistance Patterns:

MRSA dominance: Up to 85% of S. aureus isolates 3
Multidrug-resistant gram-negatives: 21.6% (P. aeruginosa, Acinetobacter) 3
Polymicrobial infections: 70.4% 3

Stewardship Principles:

NO antibiotics for non-infected wounds (most critical 3)
Culture-directed therapy (avoid empiric prolongation)
Shortest effective duration
Oral transition when appropriate
Avoid "bridge to surgery" antibiotics if surgery delayed 3

MCQ #5 (Difficult): Which statement about antibiotic resistance in pressure injuries is MOST accurate?

A) Gram-positive resistance is more common than gram-negative
B) Polymicrobial infections occur in <30% of cases
C) MRSA can represent up to 85% of S. aureus isolates in some centers
D) Anaerobic resistance is the primary concern

Answer: C - 3 specifically documents this alarming resistance pattern.

Slide 44-46: Special Populations (3 minutes)

Spinal Cord Injury Patients:

Higher recurrence after surgery 6
Sensory loss increases risk
Require lifelong prevention strategies
Electrical stimulation equally effective 6

Elderly/Nursing Home Residents:

Malnutrition common
Multiple comorbidities
Polypharmacy considerations
Transition of care challenges

ICU Patients:

Medical device-related pressure injuries
Prone positioning (COVID-19 era)
Hemodynamic instability
Vasopressor use (tissue perfusion)

Slide 47-50: Quality Improvement & Outcomes (3 minutes)

Successful QI Interventions:

Multidisciplinary Teams Reduce HAPIs:

89% reduction in full-thickness HAPIs with dedicated teams 2
4.2 percentage point decrease (5.76% to 1.59%) 1
46% reduction in length of stay 1

Key QI Components:

Standardized documentation
Staff education (especially PCTs 8)
Compliance audits
Root cause analysis of each HAPI
Unit-specific action plans

Metrics to Track:

HAPI prevalence rate
Stage distribution
Anatomical location
Time to development
Prevention bundle compliance

Slide 51-53: Case-Based Learning (5 minutes)

Case 1: The Antibiotic Trap

72-year-old nursing home resident, Stage IV sacral ulcer with exposed bone. No fever, no purulence, no erythema. Wound culture grows MRSA and P. aeruginosa. No surgery planned.

Question: What is the appropriate management?

Answer: NO systemic antibiotics 3. This is non-infected osteomyelitis without surgical plans. Focus on wound care, pressure off-loading, and nutrition. Cultures represent colonization, not infection.

Case 2: The Surgical Candidate

58-year-old paraplegic, Stage IV ischial ulcer with pelvic osteomyelitis confirmed by bone biopsy. Scheduled for debridement and flap reconstruction in 2 weeks. Currently has cellulitis.

Question: What is the antibiotic strategy?

Answer: Treat cellulitis with 5 days of antibiotics (extend if slow improvement). Do NOT prolong antibiotics as "bridge to surgery" - no benefit 3. After surgery with flap reconstruction, give 6 weeks of antibiotics 3, consider oral transition when stable.

MCQ #6 (Difficult): Which intervention has the STRONGEST evidence for improving pressure injury healing?

A) Vitamin C supplementation
B) Negative-pressure wound therapy
C) Protein-containing nutritional supplements
D) Laser therapy

Answer: C - 6 reports moderate-quality evidence for protein supplements improving wound healing, while vitamin C showed no benefit and other therapies had low-quality or mixed evidence.

Slide 54-56: TAKE-HOME MESSAGES (3 minutes)

🔑 KEY PRINCIPLES TO REMEMBER:

1. ANTIBIOTICS - THE GOLDEN RULES:

✅ Stage IV without infection = NO antibiotics 3
✅ Osteomyelitis without surgery = NO antibiotics 3
✅ Skin/soft tissue infection = 5 days (extend if slow improvement) 3
✅ Post-surgical osteomyelitis = 6 weeks 3
✅ NO "bridge to surgery" antibiotics 3
✅ Oral antibiotics adequate for many osteomyelitis cases 3

2. MICROBIOLOGY MATTERS:

🦠 S. aureus dominates (77%), up to 85% MRSA 3
🦠 70% are polymicrobial 3
🦠 21.6% gram-negatives are MDR 3
🦠 Bone biopsy > superficial cultures 3

3. PREVENTION IS PARAMOUNT:

🛏️ Air-fluidized beds reduce ulcer size 6
🍗 Protein supplements improve healing 6
❌ Vitamin C does NOT help 6
🔄 Repositioning and nutrition are most improvable 7

4. SURGICAL CONSIDERATIONS:

🔪 Sacral ulcers have lower recurrence than ischial 6
🔪 SCI patients have higher recurrence rates 6
🔪 Reoperation rate: 12-24% 6

5. RESISTANCE STEWARDSHIP:

💊 Most critical: NO antibiotics for non-infected wounds
💊 Culture-directed therapy, shortest duration
💊 Consider local antibiogram always

Slide 57: Final MCQ Challenge

MCQ #7 (Most Difficult):

A 62-year-old with complete T10 SCI develops a Stage IV sacral pressure injury. MRI shows bone marrow edema. Bone biopsy shows fibrosis and reactive bone formation, but NO polymorphonuclear or mononuclear infiltration. The wound has minimal erythema, no purulence. What is the next step?

A) Start IV vancomycin for 6 weeks
B) Start oral linezolid for 6 weeks
C) Consult surgery for immediate debridement
D) Optimize wound care and nutrition, no antibiotics

Answer: D - 3 explicitly states that pressure-related changes (fibrosis, reactive bone formation, bone marrow edema) occur in ALL Stage IV injuries regardless of osteomyelitis presence. Without histopathologic evidence of infection (inflammatory cell infiltration), this is NOT osteomyelitis. No antibiotics indicated 3.

Slide 58: Resources & References

Key Guidelines:

Clinical Infectious Diseases 2024: Pelvic Osteomyelitis in Stage IV Pressure Injuries 3
Annals of Internal Medicine 2015: ACP Clinical Practice Guideline 6
American Family Physician 2023: Prevention, Evaluation, Management 4

Quality Improvement Evidence:

HCA Healthcare Journal 2024 1
Wounds 2019 2
American Journal of Nursing 2025 7

🎯 FINAL TAKE-HOME MESSAGE:

The most common error in pressure injury management is OVERUSE of antibiotics. Exposed bone does not equal infection. Stage IV without clinical infection requires NO antibiotics. When antibiotics are indicated, use the shortest effective duration, de-escalate based on cultures, and transition to oral therapy when appropriate. Prevention through repositioning and nutrition remains more effective than any treatment.

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