Treatment of PEG Tube Infection
For established PEG tube site infections, begin with daily antimicrobial cleansing and topical antimicrobial agents, escalating to systemic broad-spectrum antibiotics if topical treatment fails, with therapy tailored based on culture results. 1
Initial Assessment and Diagnosis
Distinguish true infection from benign findings:
- Minor reddening (<5mm around the stoma) is often caused by tube movement and does not necessarily indicate infection 1
- True infection presents with loss of skin integrity, erythema >5mm, purulent and/or malodorous exudate, fever, and pain 1
- Obtain swabs for both bacterial and fungal cultures before initiating antimicrobial therapy 1
Common pathogens to expect:
- The most frequently isolated organisms are Candida species, Staphylococcus aureus, and Pseudomonas aeruginosa 2
- Infections are typically polymicrobial in 47% of cases 2
- Most organisms remain susceptible to commonly used antimicrobials, though quinolone-resistant and multidrug-resistant organisms can occur 2
Treatment Algorithm
Step 1: Local Wound Care
- 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
- Use foam dressings rather than gauze to reduce skin maceration 1
- Apply barrier films, pastes, or creams containing zinc oxide for skin protection 1
Important caveat: Avoid topical antibiotics as they may promote resistance 1
Step 2: Systemic Antibiotics (if topical treatment fails)
- Add systemic broad-spectrum antibiotics if infection does not resolve with topical treatment 1
- Tailor antibiotic therapy based on culture results 1
Specific antibiotic considerations:
- For nosocomial intra-abdominal coverage, piperacillin/tazobactam and carbapenems provide the most reliable coverage, particularly for resistant organisms like Achromobacter species 3
- Third-generation cephalosporins and fluoroquinolones (commonly used for spontaneous bacterial peritonitis) may be insufficient for resistant organisms 3
- Combined therapy with clindamycin 600mg and cefotaxime 1,000mg every 8 hours has shown efficacy in reducing acute complications 4
Step 3: Address Mechanical Factors Contributing to Infection
- Ensure proper tension between internal and external bolsters—allow at least 5mm of free movement to avoid excessive pressure that causes tissue ischemia and promotes infection 1
- Prevent leakage which leads to hyper-hydrated or inflamed skin and promotes microbial growth 1
- Use a Y-compress to avoid formation of a moist cavity under the external fixation plate 5
Special Situations
For fungal infections:
- Use topical antifungal agents 1
For excessive granulation tissue (which can harbor infection):
- Apply barrier film or cream to protect surrounding skin 1
- Consider topical antimicrobial agents, foam or silver dressings 1
- Silver nitrate cauterization can be used 1
- Topical corticosteroids for 7-10 days may be beneficial 1
High-risk populations requiring heightened vigilance:
- HIV-positive patients with advanced immunodeficiency experience higher rates of local infection at the PEG exit site, though severe complications are not more frequent than in control populations 5
- Patients with diabetes, obesity, poor nutritional status, chronic corticosteroid therapy, and other immunosuppressive therapy are at increased risk 1
Important Caveats and Pitfalls
Dressing considerations:
- Be aware of potential allergies to antimicrobial dressing components 1
- Silver dressings cannot be used during MRI procedures 1
Severe complications:
- While rare (1.6% incidence), severe complications including peritonitis can occur and require immediate medical attention 6, 3
- All infections in one cancer center study were local (cellulitis, complicated skin and skin structure infections including abdominal wall abscess) with no cases of concomitant bacteremia 2
Prevention context: