What is the recommended treatment for a PEG (Percutaneous Endoscopic Gastrostomy) tube site infection?

Treatment of PEG Tube Site Infection

For PEG tube site infections, topical antimicrobial agents should be applied first, followed by systemic broad-spectrum antibiotics if the infection persists. 1

Diagnosis and Assessment

• Site infection is a common complication after transoral gastrostomy placement, occurring in approximately 15% of cases 1
• Risk factors include diabetes, obesity, poor nutritional status, chronic corticosteroid therapy, and other immunosuppressive therapy 1
• Signs and symptoms of infection include loss of skin integrity, erythema, purulent and/or malodorous exudate, fever, and pain 1
• Distinguish between true infection and minor reddening (<5mm) around the stoma, which is often caused by movement and not necessarily infection 1
• Obtain swabs for both bacterial and fungal cultures before initiating antimicrobial therapy 1

Treatment Algorithm

First-Line Treatment

• Clean the affected skin at least once daily using an antimicrobial cleanser 1
• Apply a topical antimicrobial agent to the entry site and surrounding tissue 1
• Options include:
  • Antimicrobial ointment 1
  • Antimicrobial dressings that deliver sustained release (silver, iodine, or polyhexamethylene biguanide) 1
  • Available in various forms: foams, hydrocolloids, or alginates 1

Second-Line Treatment

• If the infection does not resolve with topical treatment, add systemic broad-spectrum antibiotics 1
• Evidence supports the use of:
  • Piperacillin/tazobactam has shown efficacy in treating polymicrobial infections 2, 3
  • Cefotaxime combined with clindamycin has shown efficacy in reducing PEG-related complications 4
• Tailor antibiotic therapy based on culture results 1

Treatment Failure

• If infection persists despite appropriate antimicrobial treatment, the tube should be removed 1
• This is especially important in cases of:
  • Stoma tract disruption 1
  • Persistent peristomal infection 1
  • Skin excoriation 1
  • Fungal infection (particularly with silicone tubes) 1

Prevention and Maintenance

• Ensure proper tension between internal and external bolsters to avoid excessive pressure 1
• Prevent leakage which can lead to hyper-hydrated or inflamed skin and promote microbial growth 1
• For skin protection, apply barrier films, pastes, or creams containing zinc oxide 1
• Use foam dressings rather than gauze to reduce skin maceration 1
• Flush the PEG tube with approximately 40 ml of water after each feed or medication to prevent residue buildup 5

Important Considerations

• Avoid using topical antibiotics as they may promote resistance 1
• Be aware of potential allergies to antimicrobial dressing components 1
• Silver dressings cannot be used during MRI procedures 1
• For fungal infections, use topical antifungal agents 1
• Antibiotic prophylaxis at the time of PEG insertion significantly reduces the risk of peristomal wound infections 6

Special Situations

• For excessive granulation tissue (which can bleed easily and be painful):
  • Apply barrier film or cream to protect surrounding skin 1
  • Consider topical antimicrobial agents, foam or silver dressings, silver nitrate cauterization, or topical corticosteroids for 7-10 days 1
• For persistent infections with resistant organisms like Achromobacter species, piperacillin/tazobactam or carbapenems may provide the most reliable coverage 7