Contiguous, Sacral pressure ulcers

 [Clin Infect Dis 2019;68:338-42]

- Osteomyelitis is not a common complication of chronic sacral pressure ulcers.

- Exposed bone is not prognostic of osteomyelitis.

- Diagnostic imaging cannot distinguish bone remodeling/fibrosis from osteomyelitis. 

- MRI, and bone biopsy (not a surface swab) after debridement are only recommended if therapeutic intervention, e.g. skin flap, is planned based on the diagnostic results.  Empiric antibiotic therapy should be withheld if possible until after the bone biopsy is complete.

- When osteomyelitis is confirmed based on bone biopsy, antibiotic therapy (oral or intravenous) is only recommended if the wound can be closed – see Osteomyelitis, Contiguous. A 2-week course of antibiotic therapy is recommended if osteomyelitis is limited to cortical bone (the majority of cases based on the literature), 4-6 weeks if medullary bone is involved.

- If the wound will not be closed and there is an acute skin/soft tissue infection surrounding the ulcer, short term (≤ 7 days) antibiotic therapy can be given – see SSTI, pressure/decubitus ulcers/ ulcers 2° to PVD.