What are the recommended antibiotics for treating an infected percutaneous endoscopic gastrostomy (PEG) tube?

Treatment of Infected PEG Tube Sites

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

Diagnosis of PEG Site Infection

Identify infection based on these clinical signs:

• Loss of skin integrity
• Erythema around insertion site
• Purulent or malodorous exudate
• Fever and pain
• Swelling or induration

Before initiating treatment, obtain swabs for both bacterial and fungal cultures to guide targeted therapy 2.

Treatment Algorithm

Step 1: Topical Management

• Clean the affected area at least once daily with antimicrobial cleanser 2
• Apply antimicrobial dressing with sustained-release properties (containing silver, iodine, or polyhexamethylene biguanide) 1
• Ensure proper external bolster tension (allow at least 5mm of free movement) to prevent pressure necrosis 2
• Apply barrier film or cream to protect surrounding skin if exudate is present 2
• Important: Avoid topical antibiotics as they are not recommended due to risk of promoting resistance 2

Step 2: Add Systemic Antibiotics (if infection persists)

For mild-moderate infections:

• First-line options:
  • Amoxicillin/clavulanate 1.2-2.2g IV every 6 hours 1
  • Ceftriaxone 2g IV daily + Metronidazole 500mg IV every 6 hours 1
  • Cefotaxime 2g IV every 8 hours + Metronidazole 500mg IV every 6 hours 1

For severe infections or healthcare-associated infections:

• First-line options:
  • Piperacillin/Tazobactam 4.5g IV every 6 hours 1
  • Cefepime 2g IV every 8 hours + Metronidazole 500mg IV every 6 hours 1

For patients with β-lactam allergies:

• Ciprofloxacin 400mg IV every 8 hours + Metronidazole 500mg IV every 6 hours 1
• Moxifloxacin 400mg IV daily 1

Step 3: Consider Tube Removal/Replacement

If infection persists despite appropriate antimicrobial treatment, consider tube removal and/or replacement in cases of:

• Stoma tract disruption
• Persistent peristomal infection
• Skin excoriation
• Fungal infection (particularly with silicone tubes) 1, 2

Special Considerations

High-Risk Patients

Patients at higher risk for infection require closer monitoring:

• Diabetes
• Obesity
• Poor nutritional status
• Chronic corticosteroid therapy
• Other immunosuppressive therapy 1, 2

Fungal Infections

• Always consider and test for fungal infections 2, 3
• Candida species are among the most common organisms isolated from infected PEG sites 3
• Use appropriate antifungal agents for confirmed fungal infections 1, 2

Common Pathogens

The most common organisms isolated from infected PEG sites include:

• Candida species
• Staphylococcus aureus
• Pseudomonas aeruginosa 3

Prevention Strategies

• Maintain proper tube care with daily cleaning during the first week after insertion using aseptic technique 2
• After initial healing (5-7 days), reduce dressing changes to once or twice weekly 2
• Cleanse with soap and water after initial healing 2
• Flush the tube with 30-40ml of water before and after each feeding and medication administration 2
• Ensure proper positioning of the external fixation plate (should retain the tube but not exert tension) 2

Common Pitfalls to Avoid

• Overtightening the external bolster (increases risk of pressure necrosis and infection)
• Using topical antibiotics (promotes resistance)
• Neglecting fungal infections
• Delaying tube removal when indicated in refractory cases
• Using unnecessary prophylactic systemic antibiotics for routine care 2

By following this evidence-based approach to managing infected PEG tube sites, clinicians can effectively treat infections while minimizing complications and improving patient outcomes.