Infection Recognition & Management in Pressure Injuries
Author: Christos Chapeshis
Date: June 2, 2026
Abstract
Pressure injuries, historically referred to as decubitus ulcers, bedsores, or pressure ulcers, remain a significant challenge in modern clinical practice, characterized by localized damage to the skin and underlying soft tissue. This article provides a comprehensive scientific review of the recognition and management of infection within these wounds, integrating the latest evidence from international clinical practice guidelines and pioneering technological advancements. A central focus is placed on the role of the nurse in early detection, the biomechanical pathways leading to tissue necrosis, and the application of advanced support surfaces like the ABeWER multiTURN® 6, the world’s first Multifunction Lateral Turning Mattress (MLTM) system. Management strategies discussed include Biofilm-Based Wound Care (BBWC), therapeutic cleansing, and the integration of dynamic pressure redistribution cushions, such as the SAFESiT® multicycle alternating pressure cushion, to mitigate the risk of infection and promote limb preservation.Figure 1. Infection management and technological innovation in pressure injury care: an overview of the topics covered in this article.
1. Introduction and Epidemiology
A pressure injury is defined as localized damage to the skin and/or underlying tissue, usually over a bony prominence or related to a medical or other device, resulting from prolonged pressure or pressure in combination with shear. While terminology has evolved, transitioning from decubitus ulcers (meaning “dead tissue due to lying down”) to pressure ulcers and finally to the internationally preferred pressure injury, the underlying etiology remains consistent: sustained mechanical loading.The significance of this condition cannot be overstated. Global prevalence in acute hospitals is reported at approximately 14.8%, with incidence rates reaching as high as 27% in critical care settings. The nurse is the frontline clinician responsible for identifying these injuries, which are often painful, costly, and preventable. For high-risk individuals, such as those with spinal cord injuries (SCI), the lifetime prevalence of developing a pressure injury is as high as 95%. Infection remains one of the most severe complications, often leading to advancing cellulitis, osteomyelitis, sepsis, and increased mortality.
2. Etiology and Pathophysiology of Infection
The development of infection in a pressure injury is intricately linked to the biomechanical forces that cause the initial wound. Tissue deformation from external loads causes ischemia by occluding blood and lymph vessels. Ischemic tissue is uniquely susceptible to infection because it lacks an adequate supply of oxygen, nutrients, and immune cells required to combat microorganism contamination.There are four primary pathophysiological pathways leading to tissue damage:
Localized Ischemia: occlusion of microvasculature leading to hypoxia.
Reperfusion Injury: oxidative stress when blood flow is restored to ischemic areas.
Direct Cell Deformation: rapid damage to cell membranes, particularly in muscle tissue, leading to deep tissue pressure injuries.
Impaired Lymphatic Function: accumulation of metabolic waste and increased edema.
In the context of bedsores, necrotic tissue acts as a nidus for infection, harboring both anaerobic and aerobic bacteria in higher densities than non-necrotic wounds. Furthermore, bacterial colonization elevates proinflammatory cytokines (e.g., interleukin-1), which increases matrix metalloproteases (MMPs) and impairs the activity of growth factors essential for healing.
3. Infection Recognition and the Wound Infection Continuum
Recognizing infection in a pressure injury requires the nurse to move beyond a simple binary “infected/not infected” assessment. The International Wound Infection Institute (IWII) defines infection along a continuum of increasing microbial burden:
Contamination: microorganisms are present but not proliferating; no host reaction is evoked.
Colonization: microorganisms are proliferating but remain in balance with the host’s immune system.
Local Infection (Covert/Subtle): the first signs of host response in chronic wounds. Indicators include delayed healing, hypergranulation (friable or bleeding), pocketing, and increased exudate.
Local Infection (Overt/Classic): characterized by erythema, local warmth, swelling, purulent discharge, and new or increasing pain.
Spreading and Systemic Infection: infection extends beyond the wound edge to surrounding tissues (cellulitis) or causes systemic responses like malaise, lethargy, and sepsis.
The nurse must maintain a high index of suspicion for infection if a pressure ulcer fails to show signs of healing within two weeks. In older adults, systemic infection may manifest as atypical signs, such as confusion, delirium, or anorexia.
3.1. The Role of Biofilms
Biofilms are present in approximately 60% of chronic wounds and represent a significant barrier to healing. These complex bacterial communities are encased in a self-produced extracellular polymeric substance (EPS), making them highly resistant to host antibodies and traditional systemic antibiotics. The nurse should suspect biofilm if a pressure injury is recalcitrant to optimal treatment and antimicrobial therapy. Confirmation typically requires high-resolution microscopy, as they are not visible to the naked eye.
4. Diagnostic Investigations
Accurate diagnosis is critical for developing a treatment plan. While surface wound swabs are commonly used, they often only identify colonizing organisms rather than those invading deeper tissues.
Tissue Biopsy: this is the gold standard for identifying the microbial load and confirming infection.
Levine Technique: if a swab is necessary, the nurse should use this method, which involves cleansing the wound, debriding nonviable tissue, and rotating the swab firmly over a 1 cm² area of healthy-looking tissue to express tissue fluid.
Probing to Bone: in Category/Stage IV decubitus ulcers, if bone is exposed or feels soft or rough, the nurse must evaluate for osteomyelitis. Probing to the bone is an accessible and inexpensive clinical test for this condition.
5. Management of Infection in Pressure Injuries
Holistic management, as advocated by ABeWER, requires addressing both the microbial burden and the mechanical environment of the wound.
5.1. Wound Bed Preparation: TIME and TIMERS
The TIMERS framework (Tissue, Infection/Inflammation, Moisture, Edge, Regeneration, Social factors) guides clinical intervention.
Tissue Management: removal of necrotic tissue through debridement is essential.
Cleansing is the first step in preparing the wound bed. The nurse should use potable water or normal saline, applied at a pressure between 4 and 15 psi to remove surface debris without damaging neoepithelium.Debridement is necessary to remove the “nidus” for infection. Methods include:
Sharp/Surgical Debridement: the fastest method for extensive necrosis or cellulitis.
Enzymatic Debridement: using collagenase to selectively liquefy necrotic tissue.
Maintenance Debridement: ongoing debridement every 24–72 hours is required to manage biofilm, as bacterial sensitivity to therapy peaks shortly after debridement.
5.3. Advanced Wound Dressings
Dressing selection must be stage-specific and based on exudate levels.
Stage 1 & 2: focus on protection and moisture balance using hydrocolloids or silicone foam dressings.
Stage 3 & 4: for deeper pressure ulcers with moderate to heavy exudate, calcium alginate or super-absorbent dressings are indicated.
Antimicrobials: silver-containing dressings or iodine-based pastes are used when local infection is confirmed or biofilm is suspected.
6. Pioneering Technology in Prevention and Management: ABeWER
The management of infection cannot be isolated from the biomechanical environment. ABeWER leads the field in pressure injury prevention protocols by shifting from manual repositioning to intelligent support surface systems.
6.1. The multiTURN® 6 MLTM System
The multiTURN® 6 is the world’s first Multifunction Lateral Turning Mattress (MLTM) system. For the immobile patient, the nurse often struggles with manual turning cycles, which can be inconsistent and physically demanding. The multiTURN® 6 automates this process, providing:
Automated Lateral Repositioning: reduces cycles of tissue deformation.
Alternating Pressure: dynamically shifts load to enhance capillary perfusion.
Continuous Low Pressure (CLP): maximizes immersion and envelopment to redistribute pressure away from bony prominences.
By maintaining optimal perfusion, the multiTURN® 6 prevents the ischemia that predisposes decubitus ulcers to infection. Its integrated heel protection is particularly vital, as the heel is the second most common site for severe pressure injuries.
6.2. Seated Protection: The SAFESiT® Cushion
For individuals who spend extended periods in chairs or wheelchairs, particularly those with SCI, seated pressure redistribution is a requirement. The SAFESiT® multicycle alternating pressure cushion (a part of the ABeWER technology portfolio) provides the necessary cyclic relief to prevent ischial tuberosity breakdown. The nurse must encourage independent users to perform weight shifts every 15 minutes, supplemented by the dynamic action of the SAFESiT® system.
7. The Nurse’s Role in Implementation and Quality Improvement
Successful prevention and management of infected pressure ulcers require a multi-faceted organizational approach. The nurse plays a dual role as both a caregiver and a clinical leader.
Clinical Leadership: appointing “wound champions” or specialized nurses has been shown to reduce pressure injury incidence.
Standardized Documentation: utilizing electronic health records and standardized staging systems (like the NPIAP/EPUAP system) ensures consistent communication across the interdisciplinary team.
Risk Screening: assessment should occur as soon as possible after admission and periodically thereafter. The nurse must evaluate not just skin status, but also nutrition, mobility, and sensory perception.
8. Pain Management and Quality of Life
Pressure injuries are universally reported as painful, which can severely impact an individual’s Health-Related Quality of Life (HRQoL). The nurse should perform a comprehensive pain assessment using validated tools like the Visual Analog Scale (VAS) or Faces Rating Scale (FRS).Pain management is especially critical during wound care procedures, such as debridement or dressing changes. The nurse should structure care around the analgesia regimen, allowing topical agents 20–30 minutes to take effect before commencing treatment. Furthermore, using low-friction turn sheets and dynamic systems like the multiTURN® 6 can minimize the pain associated with manual repositioning.
9. Conclusion
Infection in pressure injuries represents a complex interplay between microbial virulence, host susceptibility, and biomechanical loading. Recognition of covert and overt signs of infection, combined with an understanding of biofilm dynamics, is essential for the nurse in clinical practice. The integration of advanced wound dressings with cutting-edge technology from ABeWER, specifically the multiTURN® 6 MLTM system and the SAFESiT® multicycle alternating pressure cushion, offers a paradigm shift in care. By automating repositioning and optimizing the microenvironment, these systems reduce the ischemic triggers of infection and provide a stimulatory environment for healing. As healthcare moves toward intelligent support surfaces, the goal remains the preservation of skin integrity and the overall well-being of the patient.
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