Wound Care — Infected Necrotic Pressure Ulcer With Sepsis
A 72-year-old woman, bedbound from severe osteoarthritis, has a deep right heel ulcer and fever of 38.9 °C. The ulcer exposes muscle and contains wet necrotic tissue with foul-smelling discharge, and the surrounding skin is red and warm. Pedal pulses are palpable. White cell count is 22 × 10⁹/L. Intravenous antibiotics have been started after blood cultures. What is the most appropriate next step?
- A.Urgent surgical debridement of the necrotic tissueCorrect
- B.Negative-pressure wound therapy over the ulcer
- C.Switch to oral antibiotics and hydrocolloid dressing
- D.Leave the necrosis intact under a dry dressing
Explanation
This is a full-thickness pressure injury with exposed muscle, wet necrosis, purulent discharge, spreading cellulitis, fever and leucocytosis, so the dead tissue is the source of sepsis. Necrotic tissue has no blood supply, so antibiotics cannot reach it, and it feeds bacterial growth; it must be removed. Urgent sharp surgical debridement back to bleeding healthy tissue, alongside intravenous antibiotics guided by cultures, provides source control, and tissue sent from the base guides therapy and identifies osteomyelitis of the calcaneus. Negative-pressure wound therapy is contraindicated over untreated necrosis and uncontrolled infection; it becomes useful after debridement to manage exudate and promote granulation. Oral antibiotics with an occlusive dressing are inadequate for a septic patient and would seal in infection. The key exception concerns the heel: a stable, dry, intact eschar on a heel without erythema, fluctuance or drainage acts as a natural cover and is left alone. Once it becomes boggy, draining or surrounded by cellulitis, as here, it must be debrided. Perfusion should always be checked before heel debridement, because an ischaemic foot may not heal and needs vascular assessment first.
Why each option
- A.
- Correct. Wet infected necrosis with sepsis needs surgical removal for source control, alongside the intravenous antibiotics already started.
- B.
- Negative-pressure therapy must not be applied over untreated necrotic tissue or uncontrolled infection; it is used after debridement.
- C.
- Oral antibiotics and an occlusive dressing are inadequate for sepsis and leave the infected necrotic tissue in place.
- D.
- Only a stable, dry, uninfected heel eschar is left intact; wet necrosis with cellulitis and fever must be debrided.
Reference: EPUAP/NPIAP/PPPIA Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019; Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021
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