Can I apply nystatin (antifungal) cream to a red percutaneous endoscopic gastrostomy (PEG) tube site?

Management of Red PEG Tube Site with Nystatin Cream

Nystatin cream can be applied to a red PEG tube site if fungal infection is suspected, but it should not be the first-line treatment without confirming the presence of fungal colonization.

Diagnosis of PEG Site Infection

When evaluating a red PEG tube site, it's important to determine the cause of inflammation:

• Signs of infection to look for:

  • Erythema (redness)
  • Purulent or malodorous exudate
  • Loss of skin integrity
  • Pain at the site
  • Fever 1

• Risk factors that increase suspicion for infection:

  • Diabetes
  • Obesity
  • Poor nutritional status
  • Chronic corticosteroid or immunosuppressive therapy
  • Hyper-hydrated or inflamed skin due to leakage 2, 1

Treatment Algorithm

Step 1: Assess the PEG site

• Clean the site with soap and water
• Check for signs of infection versus simple irritation
• Ensure the external bolster is not too tight (should allow 5mm of free movement) 1

Step 2: Determine infection type

• If fungal infection is suspected (white plaques, satellite lesions, or previous antifungal response):

  • Swab the area for fungal culture 2
  • Nystatin cream application is appropriate 1

• If bacterial infection is suspected (purulent drainage, significant erythema):

  • Swab for bacterial culture
  • Topical antimicrobial agents are recommended first 2, 1

Step 3: Apply appropriate treatment

• For confirmed or suspected fungal infection:

  • Apply nystatin cream to the PEG tube site 1
  • Continue until signs of infection resolve

• For bacterial infection:

  • Use antimicrobial dressings (silver, iodine, or polyhexamethylene biguanide) 2
  • Add systemic antibiotics if infection is severe or doesn't respond to topical treatment 1

Important Considerations

• Avoid topical antibiotics as they can promote resistance 2

• Watch for tube material degradation with fungal infections, particularly with silicone tubes 2

• Consider tube replacement if:

  • Infection persists despite appropriate treatment
  • There is stoma tract disruption
  • Skin excoriation continues
  • Fungal infection has compromised tube integrity 2, 1

Maintenance Care

• Clean the site daily with soap and water of drinking quality 1
• Ensure proper positioning of the external fixation plate 1
• Flush the tube with 30-40ml of water before and after each feeding and medication administration 1

Pitfalls to Avoid

• Don't overtighten the external bolster - this increases risk of infection 1
• Don't neglect fungal infections - they can lead to material deterioration 2
• Don't delay tube removal when indicated in refractory cases 1
• Don't use prophylactic systemic antibiotics for routine care 1

Remember that proper identification of the infectious agent is crucial for selecting the appropriate treatment. While nystatin cream can be effective for fungal infections at PEG sites, it should be used only when a fungal infection is suspected or confirmed.