What is the management for green discharge from an unused Percutaneous Endoscopic Gastrostomy (PEG) site in a patient with an infective exacerbation of asthma?

Management of Green Discharge from Unused PEG Site in a Patient with Infective Exacerbation of Asthma

The green discharge from an unused PEG site in a patient with infective exacerbation of asthma should be treated with appropriate antibiotics while simultaneously managing the asthma exacerbation with standard therapy including bronchodilators, corticosteroids, and oxygen as needed.

Management of the PEG Site Infection

• Green discharge from a PEG site indicates bacterial infection that requires antibiotic therapy, which should be targeted based on local antimicrobial resistance patterns 1
• While antibiotics are not routinely recommended for asthma exacerbations, they are indicated when there is clear evidence of bacterial infection, such as green discharge from a PEG site 1
• Common pathogens in PEG site infections include skin flora such as Staphylococcus aureus, Streptococcus species, and gram-negative organisms 1
• Local wound care should include cleaning the site with antiseptic solution and applying appropriate dressings to absorb discharge 1

Management of Asthma Exacerbation

Initial Assessment and Treatment

• Assess severity of asthma exacerbation through clinical presentation, peak expiratory flow (PEF), and vital signs 1
• Administer oxygen to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 2
• Provide inhaled short-acting beta-agonists (SABA): albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, then adjust based on response 1, 2
• Administer systemic corticosteroids early: prednisone 40-80 mg/day or intravenous hydrocortisone 200 mg every six hours for severe cases 1, 2
• Add ipratropium bromide to SABA therapy for severe exacerbations: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2

Monitoring and Ongoing Management

• Measure and record PEF 15-30 minutes after starting treatment and thereafter according to response 1
• Continue oxygen therapy as needed to maintain appropriate saturation 1, 2
• If improving, give nebulized beta-agonist every four hours 1
• If not improving after 15-30 minutes, give nebulized beta-agonists more frequently (up to every 15 minutes) 1

Antibiotic Considerations

• While antibiotics are not routinely recommended for asthma exacerbations alone, they are indicated when there is evidence of concurrent bacterial infection 1
• The presence of green discharge from the PEG site constitutes clear evidence of bacterial infection requiring antibiotic therapy 1, 3
• Consider coverage for common skin flora and enteric organisms given the PEG site location 3
• Appropriate empiric antibiotics might include amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or a cephalosporin, depending on local resistance patterns 3

Special Considerations

• Ensure that antibiotic therapy does not interact with asthma medications, particularly theophylline 1
• Monitor for potential worsening of asthma symptoms with certain antibiotics, though this is rare with commonly used agents 4
• Consider the possibility that chronic PEG site infection could be contributing to the asthma exacerbation through systemic inflammatory response 4
• For severe asthma exacerbations not responding to initial therapy, consider adjunctive treatments such as intravenous magnesium sulfate (2g over 20 minutes) 5, 6

Discharge Planning

• Continue appropriate antibiotics for the PEG site infection for 7-10 days 3
• Provide education on proper PEG site care and signs of worsening infection 1
• Ensure standard asthma discharge medications: prednisolone tablets (30 mg daily) for 1-3 weeks, inhaled steroids at higher dosage than before admission, and inhaled beta-agonists as needed 1
• Arrange follow-up within 1 week with primary care provider and within 4 weeks with respiratory specialist 1
• Provide patient with a written asthma action plan and peak flow meter with instructions 1

Indications for Intensive Care

• Monitor for signs of deteriorating respiratory status requiring intensive care: worsening peak flow, persistent hypoxia, exhaustion, confusion, or drowsiness 1
• Consider transfer to ICU if patient develops features of life-threatening asthma despite appropriate treatment 1