Registered Nurses' Association of Ontario

Agents for Managing Infection

The preferred treatment for wounds exhibiting superficial critical colonization is local (topical) antimicrobial agents. Systemic antibiotics and debridement should be considered for deeper and surrounding bacterial infections to facilitate wound healing.


Topical Antimicrobial Agents

  • Topical antimicrobial agents (e.g., dressings, creams) are generally not recommended for the treatment of locally infected pressure injuries because of the risk of antibiotic resistance, hypersensitivity, inability to penetrate deeper pressure injuries, and uncontrolled systemic absorption of the medication when applied to larger wounds.
  • If topical antimicrobial agents are used to help control localized wound infection, these products should only be used for a short period of time. In addition, different antimicrobial products should not be applied to a wound simultaneously.


Systemic Antimicrobial Agents

  • Systemic antibiotics (i.e., antimicrobials) are used to treat deeper pressure injuries because of the potential of such ulcers to cause systemic infections such as sepsis, bacteremia, cellulitis and osteomyelitis, and death.
  • Unlike topical antimicrobial and antiseptic agents, which cannot penetrate to the base of the wound, systemic antibiotics can be used with life-threatening pressure injury infections.
  • Identification of the target pathogen(s) and confirmation of their antibiotic susceptibilities via wound swabs, tissue cultures, and sensitivity testing is required to ensure ongoing, effective antibiotic treatment.
  • Osteomyelitis can be assessed through a range of diagnostic tests, such as MRIs (gold standard, if available), x-rays, blood work (e.g., serum, ESR, CRP), biopsies, and clinical assessment. If the bone feels gritty or soft when probing during a clinical assessment and the pressure injury has either failed to heal or has reopened with treatment, the interprofessional team should suspect osteomyelitis and proceed with further investigation (i.e., referral to a medical specialist) and systemic antibiotic treatment.


Topical Antiseptic Agents

  • If there is a delay in pressure injury healing due to superficial critical colonization, antimicrobial agents should be considered before antiseptic agent.
  • Antiseptic agents should be used for a short time and should be discontinued when superficial critical colonization (localized infection) is no longer a clinical concern, once healing has progressed, or as soon as the person experiences any antiseptic-related adverse event.
  •  Antiseptic agents are most often used to reduce bacterial burden in non-healable pressure injuries, where the goal is to reduce bacterial burden rather than to heal the wound.
Clinical Management
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition
Point of Care Resources