What is the best management approach for an elderly patient with significant comorbidities and compromised swallowing function who has an infected Percutaneous Endoscopic Gastrostomy (PEG) tube?

Management of Infected PEG Tube

For an infected PEG tube in an elderly patient with comorbidities and dysphagia, initiate systemic antibiotics targeting the most common pathogens (Staphylococcus aureus, Pseudomonas aeruginosa, and Candida species), perform daily antimicrobial cleansing of the peristomal site, and assess for complications requiring tube removal or surgical intervention. 1

Immediate Assessment and Diagnosis

Examine the PEG site for signs of infection including:

• Erythema, purulent discharge, or fever indicating peristomal infection 2, 3
• Excessive granulation tissue with bleeding or pain 3, 4
• Leakage around the tube suggesting improper tension or enlarged stoma tract 2, 4
• Abdominal tenderness, rigidity, or peritoneal signs suggesting peritonitis 5

Verify proper tube positioning and tension:

• Ensure external fixation plate allows at least 5mm of free movement to prevent pressure-related complications 2
• Push tube 2-3cm ventrally and pull back to resistance of internal flange to confirm proper positioning 2
• Check that the incision is approximately 8mm to prevent pressure lesions 2

Antibiotic Selection Based on Infection Severity

For localized peristomal infection (cellulitis, purulent discharge):

• The most common organisms are Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa 1
• Most organisms remain susceptible to commonly used antimicrobials, though quinolone-resistant and multidrug-resistant organisms occur 1
• Consider empiric coverage with agents effective against both gram-positive and gram-negative organisms 1
• Obtain wound cultures to guide targeted therapy 1

For suspected peritonitis (rare but serious complication):

• Piperacillin/tazobactam or carbapenem provide the most reliable coverage, with 5 of 8 patients in case series showing clinical improvement with these agents 5
• Third-generation cephalosporins and fluoroquinolones (commonly used for spontaneous bacterial peritonitis) are insufficient for resistant organisms like Achromobacter species 5
• Cefepime and metronidazole combination may be inadequate for widely resistant pathogens 5

Local Wound Management

Daily peristomal care is essential:

• Clean the affected area at least once daily using an antimicrobial cleanser 3, 4
• Apply topical antimicrobial agents under the external fixation device 3, 4
• Use foam dressings rather than gauze to reduce skin maceration, as foam lifts drainage away from skin 3, 4
• Apply barrier film or cream containing zinc oxide to protect surrounding skin if exudate is present 2, 3

For excessive granulation tissue with infection:

• Apply topical corticosteroid cream or ointment for 7-10 days combined with foam dressing for compression 3, 4
• Consider silver nitrate cauterization applied directly to overgranulation tissue for persistent cases 3, 4
• For fungal infections, apply topical antifungal agents 3
• Surgical removal or argon plasma coagulation may be necessary for refractory cases 3, 4

Use Y-compress to prevent moist cavity formation under external fixation plate 2

Indications for Tube Removal or Replacement

Remove the PEG tube if:

• Peritonitis develops despite appropriate antibiotic therapy 5
• Abdominal wall abscess forms that cannot be adequately drained 1
• Persistent infection despite 7-10 days of appropriate systemic and local therapy 3

Important caveat: Do not replace tubes with larger-diameter tubes, as this is generally ineffective and results in enlarged stoma tract with more leakage 3, 4

For tube removal within 4 weeks of placement, seek immediate medical attention as the fibrous tract may not be established, risking intraperitoneal leakage 6, 2

Prevention Strategies for Future Infections

The evidence strongly supports prophylactic measures:

• Single-dose first-generation cephalosporin (e.g., 2.2g co-amoxiclav) administered 30 minutes before PEG placement significantly reduces peristomal infections 6, 7
• In one study, only 2 of 164 patients who received prophylactic antibiotics developed infections requiring IV therapy, compared to 4 of 4 patients without prophylaxis 7
• Covering the PEG tube during insertion with a detachable sheath reduces peristomal purulent infection by 95% (OR: 0.05,95% CI: 0.02-0.13) 8

Monitoring and Follow-up

Daily monitoring should include:

• Assessment of peristomal site for signs of worsening infection 2
• Verification of proper tube tension and positioning 2, 4
• Evaluation for systemic signs of infection (fever, elevated WBC, elevated CRP) 8

Common pitfall to avoid: Pneumonia is a major cause of death in elderly patients with dysphagia, and PEG tubes do not eliminate aspiration risk 6. Continue aspiration precautions including head-of-bed elevation and monitoring for respiratory symptoms 6.

Prognosis Considerations

In elderly patients with significant comorbidities, overall mortality within weeks of PEG placement is high, typically due to underlying conditions rather than the procedure itself 6. However, infection is a preventable complication that can be effectively managed with appropriate antibiotic selection and local wound care 7, 1, 8.