Is the management plan for a PEG (Percutaneous Endoscopic Gastrostomy) tube site infection with dark black-brown drainage, surrounding erythema, and maceration, including dressing changes with topical mupirocin, systemic amoxicillin-clavulanate, and Saccharomyces boulardii (Florastor) for gastrointestinal prophylaxis, appropriate?

Management Assessment of PEG Tube Site Infection with Dark Drainage

Your management plan is largely appropriate and follows current guideline recommendations, though there are several important modifications needed regarding the topical mupirocin regimen and consideration of the antibiotic spectrum. 1

Key Strengths of Your Approach

Systemic Antibiotic Selection

• Amoxicillin-clavulanate is an excellent first-line choice for PEG site infections, providing broad-spectrum coverage against skin flora, gram-negative organisms, and anaerobes commonly implicated in these polymicrobial infections 1, 2
• The 10-day duration is appropriate for soft tissue infection with concerning features (dark drainage, erythema, maceration) 1
• This agent has demonstrated efficacy in reducing peristomal infections in prospective randomized trials 2

Appropriate Monitoring and Escalation Plan

• Your low threshold for escalation to IV antibiotics, CT imaging, or specialty consultation is prudent given the abnormal drainage characteristics 1
• STAT ultrasound to evaluate for abscess or deeper soft tissue involvement is appropriate initial imaging 1
• Close monitoring for signs of buried bumper syndrome is essential 3, 4

Gastrointestinal Prophylaxis

• Saccharomyces boulardii (Florastor) for antibiotic-associated diarrhea prophylaxis is reasonable, though not specifically addressed in PEG infection guidelines 5

Critical Modifications Needed

Topical Mupirocin Application

• The FDA-approved dosing for mupirocin ointment is three times daily, not with every shift dressing change 6
• Mupirocin should be applied as "a small amount to the affected area three times daily" and may be covered with gauze dressing 6
• Prolonged use beyond 3-5 days without clinical response warrants re-evaluation, as extended use may promote resistance and overgrowth of nonsusceptible organisms including fungi 6
• Your 14-day duration for mupirocin is excessive; guidelines recommend 7-10 days maximum for topical antimicrobials in this context 1

Dressing Management

• Use foam dressings rather than gauze to reduce skin maceration, as foam lifts drainage away from the skin while gauze contributes to further maceration 3
• Clean the affected skin at least once daily (not every shift) using an antimicrobial cleanser 1
• Apply zinc oxide-based barrier cream or paste to protect surrounding skin from gastric content leakage 3, 1

Culture-Directed Therapy

• Obtain swabs for both bacterial and fungal cultures before initiating antimicrobial therapy to guide subsequent treatment adjustments 1
• This is particularly important given the dark black-brown drainage, which could indicate necrotic tissue, fungal involvement, or polymicrobial infection 1
• Head and neck cancer patients and those with oropharyngeal colonization have particularly high rates of concordant PEG site infections (36% in one study), emphasizing the importance of culture data 7

Additional Considerations

Risk Factors Present

• The dark drainage with surrounding erythema and maceration suggests more than simple superficial infection 1
• Distinguish this from minor reddening (<5mm) which may be mechanical rather than infectious 1

Tube Maintenance During Treatment

• Verify proper tension between internal and external bolsters—should allow at least 5mm of free movement to prevent pressure necrosis 3, 8
• Push tube 2-3cm ventrally and pull back to resistance of internal flange to ensure proper positioning 8
• Consider proton pump inhibitors if gastric content leakage is contributing to skin breakdown 3

Special Populations

• If this patient has diabetes, obesity, malnutrition, or immunosuppression, infection risk is substantially elevated and closer monitoring is warranted 1, 9
• Larger tube size (15 Fr vs 9 Fr) and less experienced operators are associated with higher infection rates 9

Common Pitfalls to Avoid

• Do not use topical antibiotics beyond 7-10 days as this promotes antimicrobial resistance 1, 6
• Avoid using mupirocin on mucosal surfaces or in patients with renal impairment where polyethylene glycol absorption could be problematic 6
• Do not ignore fungal infection possibility—local fungal infections may be associated with leakage and require topical antifungal agents 3
• Tailor antibiotic therapy based on culture results rather than continuing empiric coverage indefinitely 1

Recommended Modifications to Your Plan

Revise topical regimen to:

• Mupirocin ointment applied three times daily (not every shift) for maximum 7-10 days 1, 6
• Daily (not every shift) cleansing with antimicrobial cleanser 1
• Foam dressings instead of standard gauze 3
• Zinc oxide barrier cream to surrounding skin 3, 1

Add:

• Bacterial and fungal cultures from the site before starting treatment 1
• Assessment and optimization of tube tension/positioning 3, 8
• Consider PPI if gastric leakage is contributing 3