What is the management for an infection related to a nasogastric tube?

Management of Nasogastric Tube-Related Infections

Nasogastric tube-related infections should be promptly treated with site-specific care, appropriate antimicrobial therapy, and removal of the tube when clinically feasible to reduce morbidity and mortality.

Diagnosis and Assessment

When evaluating a patient with a suspected nasogastric tube-related infection, look for:

• Signs of local infection:

  • Erythema around insertion site
  • Purulent or malodorous exudate
  • Pain at the site
  • Loss of skin integrity 1

• Systemic signs:

  • Fever
  • Elevated inflammatory markers
  • Signs of sepsis in severe cases

• Obtain appropriate cultures:

  • Swab the site for bacterial culture if purulent drainage or significant erythema is present
  • Consider fungal culture if white plaques or satellite lesions are present 1

Treatment Algorithm

1. Local Infection (Insertion Site)

• Clean the site daily with antimicrobial cleanser 1
• Apply appropriate topical therapy based on suspected pathogen:
  • For bacterial infection: Topical antimicrobial agents or antimicrobial dressings (silver, iodine, or polyhexamethylene biguanide) 1
  • For fungal infection: Nystatin cream until signs resolve 1
• Apply barrier film or cream to protect surrounding skin if exudate is present 1

2. Systemic Infection

• For mild-moderate infections:

  • Amoxicillin/clavulanate OR
  • Ceftriaxone + Metronidazole OR
  • Cefotaxime + Metronidazole 1

• For severe or healthcare-associated infections:

  • Piperacillin/Tazobactam OR
  • Cefepime + Metronidazole 1

• For β-lactam allergy:

  • Ciprofloxacin + Metronidazole OR
  • Moxifloxacin 1

3. Tube Management

• Remove the nasogastric tube as soon as clinically indicated to reduce infection risk 2
• If continued enteral access is needed, consider:
  • Replacing the infected tube with a new one
  • Converting to a different type of enteral access (e.g., PEG tube) for long-term use

Special Considerations

Prevention of Complications

• Elevate the head of the bed 30-45° for patients with nasogastric tubes to reduce aspiration risk 2
• Routinely verify appropriate tube placement to prevent complications 2
• Assess intestinal motility (bowel sounds, residual gastric volume) and adjust feeding rate/volume to prevent regurgitation 2
• Avoid unnecessary use of nasogastric tubes, as they are associated with:
  • Increased risk of aspiration pneumonia 3
  • Poorer outcomes in Clostridium difficile infection (81% increased risk) 4
  • Colonization with gram-negative bacteria 3

Medication Administration Through Infected Tubes

• For patients requiring continued medication through infected tubes:
  • Ensure proper crushing of medications when appropriate 5
  • Flush tube with 30-40ml water before and after medication administration 1
  • Consider alternative routes if infection is severe

High-Risk Patients

Pay special attention to patients with:

• Diabetes
• Obesity
• Poor nutritional status
• Immunosuppressive therapy
• Chronic corticosteroid use
• Hyper-hydrated or inflamed skin 1

Common Pitfalls to Avoid

• Delaying tube removal when no longer needed
• Using prophylactic systemic antibiotics for routine care
• Overtightening external fixation devices
• Neglecting fungal infections
• Using topical antibiotics inappropriately 1

By following this structured approach to managing nasogastric tube-related infections, you can effectively treat the infection while minimizing complications and improving patient outcomes.