• Managing infected venous leg ulcers involves:
• Cleaning the ulcer,
• Dressing the ulcer,
• Taking a wound swab and prescribing an antibiotic,
• Following up and,
• Giving life-style advice.

• Signs of an infected venous leg ulcer include:
• Enlarging ulcer.
• Increased exudate.
• Increased pain.
• Pyrexia.
• Foul odour.
• Cellulitis: surrounding skin is red, hot and non-scaling.

• Irrigate the ulcer at each dressing change with warm tap water or saline, then dry (strict aseptic technique is not required).
• Remove slough, necrotic, fibrous, or excess granulation tissue by gentle washing.
• Debridement is not usually necessary. If debridement is being considered, the procedure should be carried out by a trained healthcare professional.
• Consider using a potassium permanganate 0.01% soak if the ulcer is malodorous.

In depth

• Take a swab for all suspected infected venous leg ulcers before prescribing an antibiotic.
• Clean the infected ulcer with tap water or saline prior to taking the swab.
• Note that venous leg ulcers should not routinely be swabbed unless there is clinical evidence of infection.

In depth

• Dressings should be applied by a healthcare professional trained in venous ulcer management.
• Wound dressing: apply a low-adherent dressing and replace on a daily basis to assess whether the infection is improving:
• Alternative dressings may be considered to help with pain (hydrocolloid), heavy exudate (alginate), or slough (hydrogels).
• Do not use antimicrobial dressings.
• Compression therapy: do not start compression therapy if the ulcer is infected. If a leg ulcer becomes infected and compression bandaging is being used, remove the bandaging, and restart compression therapy once the infection has resolved.

In depth

• Prescribe flucloxacillin (or erythromycin or clarithromycin if the person is allergic to penicillin) for 7 days, whilst awaiting swab results.
• Do not use topical antibiotics.

In depth

• Review the person within 3 days to ensure the infected ulcer is responding to treatment. Ideally, people with infected venous leg ulcers should be followed up daily or every 2–3 days until a clinical improvement is seen.
• Inspect and compare the ulcer and surrounding skin for signs of improvement, suggested by reduced inflammation, development of healthy pink granulation tissue, reducing exudate, and improving symptoms of pain, oedema, and pyrexia.
• If the infection is not responding, check swab results and consider changing the antibiotic based on sensitivity information. Consider possible complications or allergic contact dermatitis as a cause for the ongoing symptoms.
• If the infection is sensitive to the empirical antibiotic but only slowly responding and not deteriorating, review after 7 days and consider continuing the antibiotic for a further 7 days.
• If there are signs of worsening infection (spreading redness, increasing pain, and systemically unwell), consider osteomyelitis or septicaemia, and admit the person to hospital for intravenous antibiotics.
• After the infection has settled, follow up the person as for an uncomplicated venous ulcer.

In depth