How to manage infection around a PEG (Percutaneous Endoscopic Gastrostomy) tube?

Management of Infection Around PEG Tube

When a PEG tube site infection is suspected or diagnosed, apply a topical antimicrobial agent to the entry site and surrounding tissue, and if the infection cannot be resolved with topical treatment alone, add systemic broad-spectrum antibiotics. 1

Identifying PEG Site Infection

• Look for these clinical signs:
  • Loss of skin integrity
  • Erythema
  • Purulent or malodorous exudate
  • Fever and pain 1
  • Obtain swabs for bacterial and fungal cultures to guide targeted therapy

Risk Factors for PEG Site Infection

• Diabetes, obesity, poor nutritional status
• Chronic corticosteroid or immunosuppressive therapy
• Hyper-hydrated or inflamed skin due to leakage
• Excess moisture or friction from poorly secured tube 1

Step-by-Step Management Algorithm

1. Initial Assessment and Topical Treatment

• Clean the affected area at least once daily using an antimicrobial cleanser 1
• Ensure proper external bolster tension (allow at least 5mm of free movement) to prevent pressure necrosis 2
• Apply one of the following:
  • Antimicrobial ointment
  • Dressing with sustained-release antimicrobial properties (silver, iodine, or polyhexamethylene biguanide) 1
  • Barrier film or cream to protect surrounding skin if there is exudate 1

2. For Overgranulation Tissue (Common Complication)

• Apply a barrier film or cream to protect surrounding skin
• Consider one of these treatment options:
  • Topical antimicrobial agent under the fixation device
  • Foam or silver dressing over the affected area (change if significant exudate or at least weekly)
  • Cauterization with silver nitrate directly onto the overgranulation tissue
  • Topical corticosteroid cream/ointment for 7-10 days with foam dressing for compression 1

3. If Infection Persists or Worsens

• Add systemic broad-spectrum antibiotics based on culture results 1
• Common pathogens include:
  • Candida species
  • Staphylococcus aureus
  • Pseudomonas aeruginosa 3

4. For Refractory Infections

• If infection cannot be resolved despite appropriate antimicrobial treatment:
  • Remove and/or replace the gastrostomy tube 1
  • Consider tube removal in cases of:
    • Stoma tract disruption
    • Persistent peristomal infection
    • Skin excoriation
    • Fungal infection (particularly with silicone tubes) 1

Important Considerations

• Avoid overtightening the external bolster, which can increase infection risk 1
• Be aware of allergies to antimicrobial product components
• Note that silver dressings cannot be worn during MRI procedures 1
• Avoid topical antibiotics, which should not be used (use antimicrobial agents instead) 1
• Always consider and test for fungal infections, particularly in patients with silicone tubes 1

Prevention Strategies

• Maintain proper tube care with daily cleaning during the first week after insertion
• After initial healing (usually 5-7 days), reduce dressings to once or twice weekly
• Cleanse with soap and water after initial healing
• Flush the tube with 30-40ml of water before and after each feeding and medication administration 2
• Consider covering the PEG tube with a protective sheath during insertion, which has been shown to significantly reduce peristomal infection rates 4

By following this structured approach to managing PEG tube site infections, you can effectively treat existing infections and prevent future complications, ultimately improving patient outcomes and quality of life.