Infections related to pressure ulcers are always serious events because most patients with these wounds are already compromised, and open wounds provide a portal for pathogenic bacteria to enter the body. Reasons for compromise include immobility, neurologic impairment and acute or chronic organ system disease. Begin with a compromised patient, then add an infected pressure ulcer, and you have a serious medical situation that requires immediate attention.
Factors that favor microbial proliferation in a wound include immunosuppression, diabetes mellitus, edema, poor nutritional state, inadequate circulation, and the presence of dead tissue, i.e. necrosis or eschar. Once bacteria proliferate, the surrounding tissue reveals an inflammatory response that includes pain, redness, local swelling and warmth, drainage, and slough. Examination of the wound can also reveal odor, which may depend upon the type of pathogen and presence of necrosis.
There are several ways that infection can present in a pressure ulcer, and patients with severe physiologic compromise may not show all signs and symptoms. The infection can be local and involve skin and surrounding tissue resulting in cellulitis or abscess. Deep wounds can result in bone infection, or osteomyelitis. Patients with infections can have fever or altered mental status, also called delirium. Infected wounds can cause a systemic inflammatory state resulting in sepsis, which is life threatening. Some organisms can give rise to fast-spreading infection in the soft tissues called necrotizing fasciitis, which is a medical emergency usually requiring surgical exploration.
For patients with infected wounds, the treatment is generally hospitalization with intravenous antibiotics and surgical removal of slough and dead tissue upon which bacteria can feed. Unroofing of dead tissue can sometimes reveal abscess formation underneath. The wound can be treated locally with topical antibiotics or wound disinfectants such as Dakins Solution.
Once the infection is controlled, attention must be paid to healing the wound. This involves local care, offloading, mobilization of the patient, and nutrition. Surgical procedures such as debridement, revascularization, grafting, and flap advancement may be appropriate for some patients. Wound healing can be a long and challenging process, and healing is not always realistic in the presence of advanced age and underlying illness. In such cases, a palliative approach makes sense. Palliation involves acknowledging that the wound is unlikely to heal, and symptom control becomes the major priority as well as prevention of further infection. When palliative care is implemented, expectations become more realistic, and painful, expensive, and sometimes futile procedures and treatments are avoided. Clinical experience has also shown that for some patients given palliative care, the wounds can actually show signs of healing.
When palliative wounds heal, we learn that a conservative approach allows the body to mend itself on its own time, at its own pace. This can sometimes be a better alternative than a rush toward quick wound closure, but it takes patience and diligent attention, along with a skilled wound care practitioner.
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