What is the management for a patient with red-greenish drainage from a Gastrostomy (G)-tube site?

Management of Red-Greenish Drainage from G-Tube Site

Red-greenish drainage from a G-tube site indicates a site infection that requires immediate topical antimicrobial treatment, and if this fails to resolve the infection within 5-7 days, systemic broad-spectrum antibiotics must be added. 1

Initial Assessment and Diagnosis

Distinguish true infection from benign findings:

• Reddening less than 5 mm around the stoma is often caused by tube movement and is not necessarily infection 1
• True infection presents with erythema, purulent and/or malodorous exudate (the red-greenish drainage described), fever, and pain 1
• Obtain swabs for both bacterial and fungal cultures before starting antimicrobial therapy 1

Check for contributing factors:

• Verify the external bolster is not too tight—excessive pressure between internal and external bolsters increases infection risk 1
• Assess for peristomal leakage of gastric contents, which creates hyper-hydrated skin that promotes microbial growth 1
• Identify high-risk patients: diabetes, obesity, poor nutritional status, chronic corticosteroid therapy, or other immunosuppression 1

Treatment Algorithm

Step 1: Daily Antimicrobial Cleansing

• Clean the affected skin at least once daily using an antimicrobial cleanser 1

Step 2: Topical Antimicrobial Therapy

• Apply an antimicrobial ointment or dressing with sustained-release antimicrobial agents (silver, iodine, or polyhexamethylene biguanide) to the entry site and surrounding tissue 1
• Use foam or silver dressings over the affected area, changing only when significant exudate is present (at least weekly) 1
• Avoid topical antibiotics as they promote resistance 1

Step 3: Systemic Antibiotics if Topical Treatment Fails

• If infection does not resolve with topical treatment alone, add oral broad-spectrum antibiotics for 5-7 days 1
• For more systemic signs (fever, elevated white count), use intravenous broad-spectrum antibiotics 1
• Tailor antibiotic therapy based on culture results 1

Step 4: Tube Removal if Infection Persists

• If infection cannot be resolved despite topical and systemic antimicrobial treatment, remove the tube 1

Skin Protection and Wound Care

Protect surrounding skin from drainage:

• Apply barrier films, pastes, or creams containing zinc oxide to prevent skin breakdown from leaking gastric contents 1
• Use foam dressings rather than gauze—foam lifts drainage away from skin while gauze traps it and causes maceration 1

Address fungal infection if present:

• Local fungal skin infections may accompany leakage and require topical antifungal agents 1

Prevent Ongoing Leakage

Optimize tube positioning:

• Ensure proper tension between bolsters with approximately 1 cm of play between skin and external bolster 1
• Allow at least 5 mm of free movement 1
• If balloon-type tube, verify balloon volume corresponds to manufacturer's recommendations and check weekly 1

Consider proton pump inhibitors:

• PPIs can decrease leakage by minimizing gastric acid secretion, though this should be reviewed regularly 1

Important Caveats

Be aware of antimicrobial dressing considerations:

• Check for allergies to dressing components (silver, iodine, polyhexamethylene biguanide) 1
• Silver dressings cannot be worn during MRI procedures 1

Watch for signs requiring surgical intervention:

• If patient develops peritonitis despite local wound care and antibiotics, surgical intervention may be required 1
• Serious complications requiring surgery occur in fewer than 0.5% of cases when contraindications are observed 1

Consider granulation tissue:

• Excessive granulation tissue is vascular and bleeds easily, which may contribute to the red appearance of drainage 1
• If present, treat with topical antimicrobial agents, foam/silver dressings, silver nitrate cauterization, or topical corticosteroids for 7-10 days 1