What IV antibiotics are recommended for a patient with leukocytosis, abnormal drainage around the percutaneous endoscopic gastrostomy (PEG) tube, and cellulitis?

IV Antibiotic Treatment for PEG Tube-Associated Cellulitis with Leukocytosis

For a patient with leukocytosis (WBC 24), abnormal drainage around a PEG tube, and surrounding cellulitis, vancomycin plus piperacillin-tazobactam is the recommended IV antibiotic regimen. 1

Rationale for Treatment Selection

This patient presents with:

• Elevated white blood cell count (24,000/μL) indicating significant systemic inflammatory response
• Abnormal drainage around PEG tube suggesting possible abscess or deeper infection
• Cellulitis of the surrounding skin

Microbiological Considerations

1. Likely Pathogens:

   • Streptococci (most common cause of cellulitis) 1
   • Staphylococcus aureus (including possible MRSA) 1
   • Gram-negative bacteria (due to PEG tube location near GI tract) 1
   • Anaerobes (due to proximity to GI tract) 1

2. Evidence-Based Approach:

   • The high WBC count (>12,000/μL) indicates a significant systemic response requiring broad-spectrum coverage 1
   • PEG tube sites are considered complex infections involving the GI tract, requiring coverage for gram-positive, gram-negative, and anaerobic bacteria 1

Treatment Algorithm

First-Line Therapy

• Vancomycin (for MRSA and streptococcal coverage) PLUS
• Piperacillin-tazobactam (for gram-negative and anaerobic coverage) 1

Dosing:

• Vancomycin: 15-20 mg/kg IV every 8-12 hours (adjusted based on renal function)
• Piperacillin-tazobactam: 3.375-4.5g IV every 6-8 hours

Alternative Regimens (if allergies or contraindications exist)

• Linezolid (600 mg IV every 12 hours) PLUS
• Meropenem (1g IV every 8 hours) 1

OR

• Daptomycin (4-6 mg/kg IV daily) PLUS
• Cefepime with Metronidazole 1

Additional Management Considerations

1. Source Control:

   • Evaluate for abscess formation requiring drainage
   • Consider PEG tube removal/replacement if it appears to be the source of infection 1

2. Duration of Therapy:

   • Initial course of 7-14 days based on clinical response 1
   • Extend treatment if improvement is not seen within 5 days 1

3. Monitoring:

   • Daily assessment of WBC count, fever curve, and local signs of infection
   • Blood cultures are recommended due to high WBC count and increased yield in elderly patients with cellulitis 2

4. Transition to Oral Therapy:

   • Consider step-down to oral antibiotics when clinically improving with:
     • Resolution of fever for >24 hours
     • Decreasing WBC count
     • Improving local signs of infection

Important Caveats

• Do not delay broad-spectrum coverage: The high WBC count (24,000) indicates a severe infection requiring immediate broad-spectrum coverage 1
• Avoid narrow-spectrum antibiotics alone: While studies show narrow-spectrum antibiotics may be sufficient for uncomplicated cellulitis 3, this case involves a PEG tube site with abnormal drainage and high WBC count, requiring broader coverage
• Consider local resistance patterns: Adjust empiric therapy based on local hospital antibiograms
• Reassess after culture results: Narrow therapy if possible once culture and sensitivity results are available

This approach provides comprehensive coverage for the most likely pathogens while acknowledging the severity of the infection as indicated by the elevated WBC count and the anatomical location of the infection.