What is the treatment for an infected percutaneous endoscopic gastrostomy (PEG) tube site?

Treatment of Infected Percutaneous Endoscopic Gastrostomy (PEG) Tube Sites

For infected PEG tube sites, apply topical antimicrobial agents to the entry site and surrounding tissue, and if the infection cannot be resolved with topical treatment alone, add systemic broad-spectrum antibiotics. 1, 2

Assessment and Diagnosis

• Look for signs and symptoms of infection:

  • Loss of skin integrity
  • Erythema
  • Purulent and/or malodorous exudate
  • Fever and pain 1, 2

• Obtain swabs for both bacterial and fungal cultures before starting antimicrobial therapy 2

  • Common pathogens include Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa 3
  • Be aware of the emergence of methicillin-resistant Staphylococcus aureus (MRSA) as a major pathogen in PEG site infections 4

• Check for contributing factors:

  • External bolster tension (should allow at least 5mm of free movement)
  • Leakage around the tube
  • Immunosuppression (diabetes, obesity, poor nutritional status, corticosteroid therapy) 1, 2

Treatment Algorithm

Step 1: Topical Treatment

• Clean the affected area at least once daily using an antimicrobial cleanser 1
• Apply one of the following:
  • Antimicrobial ointment
  • Dressing with sustained-release antimicrobial properties (silver, iodine, or polyhexamethylene biguanide)
  • Available in different forms: foams, hydrocolloids, or alginates 1, 2
• Ensure proper external bolster tension, allowing 5mm of free movement 1
• Apply barrier film or cream to protect surrounding skin if there is exudate 2

Step 2: If Infection Persists

• Add systemic broad-spectrum antibiotics based on culture results 1
• Avoid topical antibiotics as they are not recommended 1
• For fungal infections, use appropriate antifungal agents 1

Step 3: If Infection Still Persists

• Consider tube removal and/or replacement if:
  • Infection persists despite appropriate antimicrobial treatment
  • Stoma tract disruption occurs
  • Skin excoriation develops
  • Fungal infection is present (particularly with silicone tubes) 1, 2

Prevention and Maintenance

• Maintain proper tube care:

  • Clean the site daily during the first week after insertion using aseptic technique
  • After stoma healing (usually 5-7 days), reduce dressings to once or twice weekly 1
  • Cleanse with soap and water of drinking quality after initial healing 1

• Ensure proper positioning:

  • External fixation plate should retain the tube but not exert tension
  • Allow free movement of at least 5mm 1

• Flush the tube with 40ml of water after feed or medication administration 1

Special Considerations

• Patients at higher risk for infection include those with:

  • Diabetes
  • Obesity
  • Poor nutritional status
  • Chronic corticosteroid therapy
  • Other immunosuppressive therapy 1

• Be aware of allergies to antimicrobial product components 1

• Silver dressings cannot be worn during magnetic resonance imaging procedures 1

Common Pitfalls to Avoid

• Overtightening the external bolster, which can cause pressure necrosis and increase infection risk 2
• Using topical antibiotics, which can promote resistance 1, 2
• Neglecting fungal infections, which should always be considered and tested for 1, 2
• Delaying tube removal when indicated in refractory cases 1, 2

By following this structured approach to PEG site infections, most cases can be successfully treated with topical antimicrobial agents alone, with systemic antibiotics reserved for more severe or persistent infections.