What is the treatment for cellulitis around a percutaneous endoscopic gastrostomy (PEG) site?

Treatment of Cellulitis Around a PEG Site

For cellulitis around a PEG site, initiate topical antimicrobial treatment with daily sterile dressing changes, and if this fails to resolve the infection within 24-48 hours, add systemic broad-spectrum antibiotics covering both streptococci and staphylococci (including MRSA if risk factors present). 1

Initial Management Approach

First-Line Treatment

• Begin with topical antimicrobial agents applied directly to the PEG entry site and surrounding tissue, combined with daily sterile dressing changes 1
• Obtain a swab for microbiological examination before initiating treatment 1
• Ensure the external bolster is not too tight, as excessive pressure between internal and external bolsters promotes infection 1
• Address any underlying causes: check for leakage, excess moisture, or tube movement that may be contributing to infection 1

When to Escalate to Systemic Antibiotics

• If topical treatment fails to resolve the infection, add systemic antibiotics 1
• Systemic therapy is indicated when there is persistent local infection despite antiseptic measures 1

Antibiotic Selection

Empirical Oral Therapy (Outpatient)

• For mild to moderate PEG site cellulitis without systemic signs, use oral antibiotics covering both streptococci and staphylococci 1
• First-line options include:
  • Cephalexin 2
  • Dicloxacillin 2
  • Amoxicillin-clavulanate 2

MRSA Coverage Considerations

• Add MRSA coverage if any of the following risk factors are present: 2
  • Previous MRSA infection or known colonization
  • Diabetes, obesity, or immunosuppression 1
  • Chronic corticosteroid therapy 1
  • Failure to respond to beta-lactam therapy after 48 hours 2
• MRSA-active options include: 1
  • Trimethoprim-sulfamethoxazole 3
  • Clindamycin 3
  • Doxycycline 1

Severe Infections Requiring Hospitalization

• For severe infections with systemic signs (fever, altered mental status, hemodynamic instability), use broad-spectrum IV antibiotics: 1
  • Vancomycin plus piperacillin-tazobactam 1
  • Vancomycin plus a carbapenem 1

Treatment Duration and Monitoring

Duration

• Standard treatment duration is 5 days, but extend therapy if the infection has not improved within this timeframe 1, 2
• Continue treatment until clear clinical improvement is documented 1

Follow-Up Assessment

• Re-evaluate within 24-48 hours to assess response to therapy 2
• Consider changing antibiotics if no improvement after 48 hours 2
• Monitor for signs of progression: increasing erythema, purulent drainage, fever, or systemic symptoms 1

Adjunctive Measures

Local Wound Care

• Inspect the wound daily during dressing changes, carefully noting any progression of erythema 1
• Apply barrier film or cream to protect surrounding skin if there is exudate 1
• Consider foam or silver dressings for exudative wounds, changed weekly or when saturated 1
• Elevation of the affected area is recommended to reduce edema 1, 2

Address Predisposing Factors

• Identify and treat underlying conditions that promote infection: 1
  • Excessive tube movement or friction 1
  • Leakage of gastric contents 1
  • Overgranulation tissue 1
  • Improper tube tension 1

Common Pitfalls to Avoid

• Do not dismiss mild erythema (<5mm) as infection initially—this is often mechanical irritation from tube movement and does not require antibiotics 1
• Avoid delaying systemic antibiotics when topical treatment clearly fails—persistent infection after 24-48 hours of appropriate local care warrants escalation 1
• Do not overlook MRSA risk factors in diabetic, obese, or immunosuppressed patients—these populations require broader initial coverage 1, 2
• Ensure adequate antibiotic duration—stopping at 5 days when infection is not fully resolved leads to treatment failure 1
• Check balloon volume weekly if using balloon-type tubes—deflation can cause tube migration and worsen infection 1