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Going to celebrate the new / advancing trainees by some #idtips that do not involve COVID.
1) Infected pressure ulcers. Must read paper by @BradSpellberg
https://academic.oup.com/cid/article/68/2/338/5050260
Basic principles below
(PS happy Canada day to all
)
1) Infected pressure ulcers. Must read paper by @BradSpellberg
https://academic.oup.com/cid/article/68/2/338/5050260
Basic principles below
(PS happy Canada day to all
)
1) Evaluate the wound- probe to bone not definitive, nor is CT or MRI - compared to bone biopsy lots of false +
2) Also needs an evaluation for sx of infxn not just depth
2) Evaluate the patient - what lead to the ulcer, is it reversible, what is their general long term prognosis
2) Also needs an evaluation for sx of infxn not just depth
2) Evaluate the patient - what lead to the ulcer, is it reversible, what is their general long term prognosis
Answer is not always prolonged antibiotics. Poor prognostic markers in those with complex illnesses - esp with end stage cognitive/organ dz. In some series 60-80% 1 year mortality. This may be a trigger for GOC discussions rather than futility with abx --> aim for 2-4 weeks
If patient has good prognosis then consider aggressive therapy. Bone biopsy, plastics and wound care support for debridement, consider adjunctive therapies (NWPT), and a plan for eventual wound closure, as well as optimizing nutrition, sugars, offloading, fecal/urine diversion
Maximum 6 weeks abx, broad spectrum (gram pos/neg/anerobe) but not necessarily anti-pseudomonal. Use correctly done swabs (debrided, clean base, deep tissue specimen) or bone bx to determine if pseudo or other resistant orgs. Oral = IV if bioavailabity/bone penetration optimal
Bottom line - evaluate patient with wound. Not all patients require prolonged therapy. Stage as patient with good 1 year prognosis or bad. For good, go aggressive and multidisciplinary. For bad, work to palliative support and 2-4 weeks abx to control sepsis/inflammation
