What is the recommended antibiotic prophylaxis for percutaneous gastrostomy (PEG) tube placement?

From the Guidelines

Antibiotic prophylaxis is recommended for percutaneous gastrostomy tube placement to reduce the risk of peristomal infection, with cefazolin being the preferred antibiotic choice, as recommended by the American Society for Gastrointestinal Endoscopy 329. The rationale for prophylaxis is that gastrostomy tube placement creates a direct communication between the skin and stomach, introducing skin flora into a normally sterile environment.

• The preferred regimen is a single dose of cefazolin 1-2g IV, which targets common skin pathogens like Staphylococcus aureus and streptococci, as well as enteric gram-negative organisms that may be encountered during the procedure 1.
• For patients with beta-lactam allergy, alternatives include clindamycin 600-900mg IV or vancomycin 15mg/kg IV (maximum 2g), as suggested by various guidelines, including the Australian Therapeutic Guidelines 326 and the French Society of Anesthesia and Intensive Care Medicine 327.
• Proper skin preparation with chlorhexidine and sterile technique remain essential components of infection prevention alongside antibiotic prophylaxis.
• The use of antibiotic prophylaxis should be limited to the perioperative period, as extended courses do not provide additional benefit and may contribute to antibiotic resistance, as noted by the American Society of Health-Systems Pharmacists, Infectious Diseases Society of America, Surgical Infection Society, and Society for Healthcare Epidemiology of America 331.
• It is also important to consider the local epidemiology and resistance patterns when selecting an antibiotic for prophylaxis, as recommended by the Canadian urological association 330 and the UK National Institute for Health and Care Excellence 328.

From the Research

Antibiotic Prophylaxis for Percutaneous Gastrostomy Tube Placement

• The use of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG) has been studied to determine its effectiveness in reducing peristomal wound infections 2, 3, 4, 5.
• A prospective randomized clinical trial found that antibiotic prophylaxis significantly reduces the risk of peristomal wound infection associated with PEG insertion 2.
• Another study found that the combined use of short-term cefotaxime and clindamycin is effective in reducing the incidence of acute complications due to PEG placement without increasing side-effects 3.
• However, a study found that a single dose of Cefazolin prophylaxis does not reduce the overall peristomal wound infection in PEG, but patients receiving prior extended antibiotic therapy have fewer peristomal wound infections 4.
• A systematic review of 13 randomized controlled trials found that administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection 5.

Recommendations for Antibiotic Prophylaxis

• The use of antibiotic prophylaxis is recommended as a general measure in percutaneous endoscopic gastrostomy to reduce the risk of peristomal wound infection 2, 5.
• The choice of antibiotic and duration of prophylaxis may vary depending on the patient's medical history, physical examination, and imaging prior to the procedure 6.
• A combined antibiotic therapy of clindamycin and cefotaxime has been shown to be effective in reducing acute post-PEG procedure complications 3.

Considerations for Gastrostomy Tube Placement

• Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events 6.
• The endoscopist should consider the patient's medical history, physical examination, and imaging prior to the procedure to tailor the appropriate approach and reduce the risk of adverse events 6.