What is the best approach to manage an infected percutaneous endoscopic gastrostomy (PEG) site in a hospice patient?

Management of Infected PEG Site in Hospice Patients

For infected percutaneous endoscopic gastrostomy (PEG) sites in hospice patients, topical antimicrobial treatment should be initiated first, followed by systemic antibiotics only if the infection cannot be resolved with topical treatment alone. 1

Initial Assessment and Diagnosis

• Signs of PEG site infection include:
  • Loss of skin integrity
  • Erythema extending >5mm around stoma
  • Purulent and/or malodorous exudate
  • Fever and pain 1
• Obtain swabs for both bacterial and fungal cultures before starting antimicrobial therapy 1
• Assess for contributing factors:
  • External bolster that's too tight (causing pressure between internal and external bolster)
  • Excessive tube movement
  • Leakage causing skin maceration
  • Immunosuppression (common in hospice patients) 1

Treatment Algorithm

Step 1: Topical Management

• Clean the affected area minimum once daily using an antimicrobial cleanser 1
• Apply antimicrobial ointment or dressing with sustained-release antimicrobial properties 1
  • Options include dressings with silver, iodine, or polyhexamethylene biguanide
  • Available in forms such as foams, hydrocolloids, or alginates
• Ensure proper external bolster tension (should allow at least 5mm of free movement) 1
• Apply barrier film or cream to protect surrounding skin if there is exudate 1

Step 2: If Infection Persists

• Add systemic broad-spectrum antibiotics based on culture results 1
• Important: Avoid topical antibiotics as they are not recommended 1

Step 3: For Refractory Infections

• Consider tube removal if infection persists despite appropriate antimicrobial treatment 1
• This is especially important in cases of:
  • Stoma tract disruption
  • Persistent peristomal infection
  • Skin excoriation
  • Fungal infection (particularly with silicone tubes) 1

Special Considerations for Hospice Patients

• Focus on comfort and quality of life rather than aggressive interventions 1
• Consider the patient's overall prognosis when deciding on treatment intensity
• For patients with limited life expectancy, prioritize symptom management over tube replacement
• Avoid unnecessary procedures that may cause discomfort without significant benefit

Prevention Strategies

• Maintain proper tube care with regular cleaning and dressing changes 1
• Ensure proper positioning of the tube with adequate external bolster tension 1
• Flush the tube with 30-40ml of water before and after each feeding and medication administration 2
• Address contributing factors:
  • Manage leakage promptly with appropriate skin barriers 1
  • For granulation tissue: consider silver nitrate cauterization, topical corticosteroid, or foam dressing 1
  • For fungal infections: use topical antifungal agents 1

Common Pitfalls to Avoid

1. Overtightening the external bolster - causes pressure necrosis and increases infection risk 1
2. Using topical antibiotics - not recommended and may promote resistance 1
3. Neglecting fungal infections - always consider and test for fungal pathogens 1
4. Unnecessary prophylactic systemic antibiotics - not indicated for routine care 1
5. Delaying tube removal - when indicated in refractory cases, prompt removal may be necessary 1

Evidence Quality and Considerations

The recommendations are primarily based on the 2022 ESPEN practical guideline for home enteral nutrition 1, which provides the most recent and comprehensive guidance for managing PEG site infections. Studies have shown that PEG site infections occur in approximately 15% of cases 1, with higher rates observed in immunocompromised patients 1. While antibiotic prophylaxis at the time of PEG placement is recommended 1, ongoing prophylaxis is not indicated for routine care.