Bedsore medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
Management of bedsore is a multidisciplinary approach which includes infection control, nutritional support and educating the caregiver. Septic ulcers should be treated with appropriate antibiotics and parenteral antibiotics are preferred over topical antibiotics if the ulcer is inflamed. | |||
==Medical Therapy== | ==Medical Therapy== | ||
The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment. | The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment. | ||
===Infection control=== | ===Infection control=== | ||
Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include [[fever]], [[pain]], [[erythema]], [[oedema]], and warmth of the area, not to mention [[pus|purulent discharge]]. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus. | Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include [[fever]], [[pain]], [[erythema]], [[oedema]], and warmth of the area, not to mention [[pus|purulent discharge]]. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus. | ||
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===Nutritional support=== | ===Nutritional support=== | ||
Upon admission, the patient should have a consultation with a [[dietitian]] to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietition should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check [[serum albumin]] and [[lymphocyte]] counts. Additionally, a bioelectric impedance analysis should be considered. | Upon admission, the patient should have a consultation with a [[dietitian]] to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietition should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check [[serum albumin]] and [[lymphocyte]] counts. Additionally, a bioelectric impedance analysis should be considered. | ||
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===Educating the caregiver=== | ===Educating the caregiver=== | ||
In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things. | In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things. | ||
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==Antimicrobial Regimen== | ==Antimicrobial Regimen== | ||
=== | ===Ulcerated Skin: Venous/Arterial Insufficiency; Pressure With Secondary Infection (Infected Decubiti) Treatment=== | ||
* | * Ulcerated skin: venous/arterial insufficiency; pressure with secondary infection (infected decubiti) treatment<ref name="pmid24126647">{{cite journal| author=Greer N, Foman NA, MacDonald R, Dorrian J, Fitzgerald P, Rutks I et al.| title=Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review. | journal=Ann Intern Med | year= 2013 | volume= 159 | issue= 8 | pages= 532-42 | pmid=24126647 | doi=10.7326/0003-4819-159-8-201310150-00006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24126647 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24347199 Review in: Evid Based Med. 2014 Jun;19(3):91] </ref> | ||
:* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h ({{or}} [[Meropenem]] 1 g IV q24h {{or}} [[Doripenem]] 500 mg IV q8h) | :* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h ({{or}} [[Meropenem]] 1 g IV q24h {{or}} [[Doripenem]] 500 mg IV q8h) | ||
:* Preferred regimen (2): [[Ticarcillin-Clavulanate]] 3.1 g IV q8h | :* Preferred regimen (2): [[Ticarcillin-Clavulanate]] 3.1 g IV q8h | ||
:* Preferred regimen (3): [[Piperacillin-Tazobactam]] 3.375 g IV q6h | :* Preferred regimen (3): [[Piperacillin-Tazobactam]] 3.375 g IV q6h | ||
:* Preferred regimen (4): [[Ertapenem]] 1 g IV q24h | :* Preferred regimen (4): [[Ertapenem]] 1 g IV q24h | ||
:* Alternative regimen (1): [[Ciprofloxacin]] 500 mg PO bid {{or}} [[Levofloxacin]] PO 500 mg qd {{and}} [[Metronidazole]] 500 mg PO qid | |||
:* Alternative regimen (2): [[Cefepime]] 2 g IV q12h {{or}} [[Ceftazidime]] 2 g IV q8h {{and}} [[Metronidazole]] 500 mg PO qid | |||
:* Note (1): If gram positive cocci on gram stain add [[Vancomycin]]. | |||
:* Note (2): If the ulcer is inflamed, treat with parenteral antibiotics with no topical treatment. | |||
:* Note (3): If the ulcer is not clinically inflamed, consider debridement, removal of foreign body, reduce the pressure for weight bearing limbs and leg elevation. | |||
:* Note (4): If not inflamed, healing improved on air bed, protein supplement, radiant heat and electric stimulation. | |||
:* Note (5): Avoid [[chlorhexidine]] and [[povidone iodine]] as it may harm the granulation tissue. | |||
==See also== | |||
* [[Venous ulcer]] | |||
* [[Peripheral arterial disease]] | |||
==References== | ==References== | ||
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{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category: Infectious Disease Project]] | |||
Latest revision as of 14:09, 17 August 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Template:AB
Overview
Management of bedsore is a multidisciplinary approach which includes infection control, nutritional support and educating the caregiver. Septic ulcers should be treated with appropriate antibiotics and parenteral antibiotics are preferred over topical antibiotics if the ulcer is inflamed.
Medical Therapy
The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment.
Infection control
Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include fever, pain, erythema, oedema, and warmth of the area, not to mention purulent discharge. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.
In order to eliminate this bioburden, it is imperative to apply antiseptics and antimicrobials at once. It is not recommended to use hydrogen peroxide for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm can be used on smaller wounds to both provide comfort and protect them from outside air and infections.
It is not recommended to use systemic antibiotics to treat infection of a bedsore, as it can lead to bacterial resistance.
Nutritional support
Upon admission, the patient should have a consultation with a dietitian to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietition should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin and lymphocyte counts. Additionally, a bioelectric impedance analysis should be considered.
If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese, selenium and zinc. It is very important that intake of these vitamins and minerals be overseen by a physician, as many of them can be detrimental in incorrect dosages.
Educating the caregiver
In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one's pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things.
As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.
Antimicrobial Regimen
Ulcerated Skin: Venous/Arterial Insufficiency; Pressure With Secondary Infection (Infected Decubiti) Treatment
- Ulcerated skin: venous/arterial insufficiency; pressure with secondary infection (infected decubiti) treatment[1]
- Preferred regimen (1): Imipenem 0.5 g IV q6h (OR Meropenem 1 g IV q24h OR Doripenem 500 mg IV q8h)
- Preferred regimen (2): Ticarcillin-Clavulanate 3.1 g IV q8h
- Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q6h
- Preferred regimen (4): Ertapenem 1 g IV q24h
- Alternative regimen (1): Ciprofloxacin 500 mg PO bid OR Levofloxacin PO 500 mg qd AND Metronidazole 500 mg PO qid
- Alternative regimen (2): Cefepime 2 g IV q12h OR Ceftazidime 2 g IV q8h AND Metronidazole 500 mg PO qid
- Note (1): If gram positive cocci on gram stain add Vancomycin.
- Note (2): If the ulcer is inflamed, treat with parenteral antibiotics with no topical treatment.
- Note (3): If the ulcer is not clinically inflamed, consider debridement, removal of foreign body, reduce the pressure for weight bearing limbs and leg elevation.
- Note (4): If not inflamed, healing improved on air bed, protein supplement, radiant heat and electric stimulation.
- Note (5): Avoid chlorhexidine and povidone iodine as it may harm the granulation tissue.
See also
References
- ↑ Greer N, Foman NA, MacDonald R, Dorrian J, Fitzgerald P, Rutks I; et al. (2013). "Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review". Ann Intern Med. 159 (8): 532–42. doi:10.7326/0003-4819-159-8-201310150-00006. PMID 24126647. Review in: Evid Based Med. 2014 Jun;19(3):91