Comprehensive clinical management of an extensive lumbo-sacral wound with multiple sinuses in an elderly male

Linda Dharmaraj1, Z. Ahamed Rithabudin2

Clinical Pharmacist, Kauvery Hospital, Alwarpet, Chennai

Clinical Pharmacist, Kauvery Group of Hospitals, Chennai

Abstract

This case report presents the detailed management of a 77-year-old male with an extensive lumbo-sacral wound associated with multiple draining sinuses. The patient underwent extensive surgical wound debridement and biopsy to rule out deep-seated infection, including tuberculosis or fungal etiology. The clinical pharmacist’s role included ensuring appropriate preoperative antibiotic prophylaxis, monitoring postoperative antibiotic therapy according to culture and sensitivity results, and optimizing supportive pharmacotherapy. The report highlights the multidisciplinary approach in managing complex soft tissue infections in geriatric patients, focusing on infection control, rational antibiotic use, and wound healing optimization.

Introduction

Extensive soft tissue infections of the lumbo-sacral region with sinus formation are uncommon and often indicate chronic, deep-seated infections such as tuberculosis, chronic bacterial abscess, or post-surgical wound infection. In elderly patients, such infections may progress insidiously due to age-related immune decline and comorbidities, requiring meticulous evaluation and management.

Wound infections in geriatric patients present unique challenges: delayed healing, poor skin integrity, polypharmacy, and risk of antibiotic resistance. The clinical pharmacist’s role in such cases is critical—ensuring appropriate antibiotic selection, dosage adjustment based on renal/hepatic status, and prevention of drug–drug interactions.

This case report aims to detail the comprehensive clinical and pharmaceutical management of a patient with a chronic lumbo-sacral wound and multiple sinus tracts.

Case Presentation

Chief Complaint

A 77-year-old male presented with complaints of a non-healing wound in the lumbo-sacral region, associated with pain, discharge, and multiple sinus openings over the lower back for the past several weeks.

History of Present Illness

The patient noticed a small area of swelling and redness in the lumbo-sacral region that gradually increased in size, later discharging purulent material. Over time, multiple sinus openings developed with foul-smelling discharge. There was no history of trauma or recent surgery at the site.

He reported generalized weakness and occasional low-grade fever. There was no history of tuberculosis, diabetes mellitus, or long-term steroid use. No neurological symptoms such as limb weakness or bladder/bowel incontinence were reported.

Past Medical and Surgical History

No significant past medical history of diabetes, hypertension, or tuberculosis.

No prior surgeries in the same region.

Medication History

No chronic medications prior to admission.

No known drug allergies.

Personal and Social History

Non-smoker, non-alcoholic.

Independent in activities of daily living prior to illness.

Investigations

Laboratory Findings (Preoperative)

ParameterResultRemarks
Hemoglobin11.5 g/dLMild anemia
Total Leukocyte Count12,800 /µLElevated – likely infection
ESR52 mm/hrMarkedly raised
Blood Urea34 mg/dLNormal
Serum Creatinine1.1 mg/dLNormal
Blood Sugar (Fasting)96 mg/dLNormal
Liver Function TestsWithin normal limitsNormal

Imaging

MRI

  • Multifocal collection involving the right quadratus lumborum, iliacus, and psoas muscles extending up to the lesser trochanter.
  • Associated subcutaneous inflammatory changes at lumbo-sacral region with air pockets, ulceration, and STIR hyperintensity near the right L5 pedicle.
  • Suggestive of deep-seated abscess with possible chronic infection.

Preoperative Management

  • Routine blood investigations and MRI evaluation done.
  • Patient assessed by anesthesiology team and declared fit for surgery (ASA Grade II).
  • Informed consent obtained for surgery and anesthesia.
  • Prophylactic intravenous antibiotics initiated preoperatively (as per institutional infection control policy).
  • Supportive medications: analgesic, antiemetic, and PPI initiated.
  • Wound region cleansed and prepared aseptically before surgery.

Surgical Procedure

Procedure

Extensive wound debridement and biopsy of large lumbo-sacral wound/sinuses under general anesthesia in prone position.

Intraoperative Findings

  • Extensive skin induration and sodden skin over lumbo-sacral and iliac regions.
  • Multiple cutaneous sinuses posteriorly draining seropurulent material.
  • Granulation tissue and necrotic debris beneath skin.

Surgical Steps

  • A transverse elliptical incision was made to excise all sinus tracts.
  • Complete excision of necrotic tissue and unhealthy granulation tissue performed.
  • Samples sent for:
    • Histopathological examination
    • AFB stain and culture
    • Fungal stain and culture
    • Gram stain
    • GeneXpert (TB confirmation)
    • Tissue culture and sensitivity (C/S)
  • Thorough wound debridement performed with copious irrigation using antiseptic saline solution.
  • Hemostasis achieved.
  • Two corrugated drains placed to facilitate postoperative drainage.
  • Wound dressed with povidone-iodine antiseptic and sterile gauze.
  • Intraoperative blood loss: Minimal
  • Duration: Approximately 90 minutes

Postoperative Management

Immediate Postoperative Care

  • Patient shifted to recovery ward and closely monitored for vital signs, pain, and wound status.
  • Postoperative period remained uneventful.

Medications Administered

CategoryDrug/ RouteDose / FrequencyPurpose
AntibioticPiperacillin-Tazobactam IV4.5 g every 8 hoursEmpirical therapy (adjusted post C/S report)
AnalgesicParacetamol IV1 g every 8 hoursPain control
Proton Pump InhibitorPantoprazole IV40 mg once dailyGastric protection
AntiemeticOndansetron IV4 mg PRNNausea prevention
TopicalPovidone-iodine dressingDailyWound antisepsis

Culture Results

  • Tissue culture grew Staphylococcus aureus (sensitive to Linezolid and Amikacin).
  • Antibiotic regimen tailored accordingly to IV Linezolid 600 mg BID for 7 days.

Clinical Pharmacist’s Role

Preoperative Phase:

  • Verified antibiotic prophylaxis timing and selection (administered within 60 min of incision).
  • Checked for potential drug interactions and renal dose adjustments.

Intraoperative Support:

  • Ensured correct antibiotic continuation during procedure.
  • Monitored anesthetic drug compatibility and post-surgical analgesia plan.

Postoperative Phase:

  • Reviewed all prescribed drugs for duplication or contraindications.
  • Monitored for adverse effects (e.g., nephrotoxicity, hepatotoxicity).
  • Ensured wound culture-based antibiotic modification.
  • Provided discharge counseling on wound hygiene and medication adherence.

Outcome and Follow-Up

  • The patient demonstrated steady clinical improvement by postoperative day 2.
  • Drain output decreased progressively, with no signs of recurrent infection or systemic complications.
  • Discharged on 20.08.2025 with the following prescriptions:
  • Linezolid 600 mg PO BID for 7 days.
  • Paracetamol 500 mg PO TID as needed for pain.
  • Pantoprazole 40 mg PO OD for gastric protection.
  • Advised daily wound dressing and review after 5 days.
  • Follow-up with general physician scheduled for reassessment and suture review.
  • At follow-up, the wound showed healthy granulation and satisfactory healing.

Discussion

Extensive lumbo-sacral wounds with multiple sinus tracts can result from chronic bacterial infections, tubercular abscesses, or necrotizing soft tissue infections. The proximity of the infection to spinal and psoas structures necessitates urgent diagnosis and aggressive management.

In this case, early MRI imaging enabled detection of multifocal collections, guiding the surgical plan. The choice of broad-spectrum antibiotics (piperacillin-tazobactam) followed by targeted therapy (linezolid) based on culture sensitivity exemplifies rational antimicrobial stewardship.

The clinical pharmacist’s involvement ensured:

  • Rational selection and timing of antibiotics.
  • Dose optimization.
  • Monitoring adverse drug reactions.
  • Coordination between surgical and medical teams for continuity of care.

Elderly patients are prone to slower recovery due to diminished tissue repair and comorbidities, making multidisciplinary follow-up essential. Postoperative wound hygiene, nutritional support, and early physiotherapy contribute to faster healing.

Conclusion

This case demonstrates the successful management of a complex lumbo-sacral wound with multiple sinus tracts in an elderly patient through a coordinated, evidence-based approach involving surgery, targeted antibiotic therapy, and vigilant clinical pharmacy oversight. Such cases highlight the importance of multidisciplinary collaboration in preventing chronic infection recurrence and ensuring optimal patient outcomes.

References

  1. World Health Organization. Guidelines for the prevention and management of wound infections. Geneva: WHO; 2018.
  2. Gupta S, et al. “Management of chronic soft tissue infections in geriatric patients.” Indian Journal of Surgery. 2020;82(3):456–462.
  3. Bratzler DW, et al. “Clinical practice guidelines for antimicrobial prophylaxis in surgery.” Am J Health-Syst Pharm. 2013;70(3):195–283.
  4. Nair P, et al. “Role of clinical pharmacists in surgical wards: A prospective interventional study.” J Clin Pharm Ther. 2022;47(5):639–647.
  5. Mangram AJ, et al. “Guideline for prevention of surgical site infection.” Infect Control Hosp Epidemiol. 1999;20(4):250–278

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