What antibiotics should be administered prior to a Percutaneous Endoscopic Gastrostomy (PEG) procedure?

Antibiotic Prophylaxis Before PEG Placement

Administer a single intravenous dose of 2 grams of cefazolin (a first-generation cephalosporin) 30-60 minutes prior to PEG tube placement to prevent peristomal wound infection. 1, 2

Recommended Prophylactic Regimen

• Cefazolin 2g IV is the gold standard antibiotic prophylaxis for PEG placement, administered as a single dose within one hour before the procedure 1, 2
• This regimen provides effective coverage against the primary pathogens responsible for peristomal infections: methicillin-sensitive Staphylococcus aureus and streptococci 2
• The antibiotic should be given under sterile surgical conditions as part of the standard preparation protocol 1

Evidence Supporting Prophylaxis

• Multiple studies demonstrate clinical benefit of single-dose antibiotic prophylaxis in reducing inflammatory complications and wound infections at the PEG site 1
• A single dose of a broad-spectrum antibiotic covering anaerobes has been shown to reduce peristomal infection rates in general populations 1
• European and American Societies of Gastrointestinal Endoscopy officially recommend single intravenous antibiotic prophylaxis for all patients undergoing PEG insertion 1

Alternative Regimens for Penicillin Allergy

• For patients allergic to beta-lactams: Use clindamycin 600mg IV as a single dose, which provides coverage against both gram-positive organisms and anaerobes 3
• Vancomycin 1g IV over 1-2 hours can be considered as an alternative in patients with severe penicillin allergy 1

Special Populations Requiring Prophylaxis

• HIV-positive patients with advanced immunodeficiency are at higher risk for local PEG site infections and should receive antibiotic prophylaxis using the same regimen 1, 4
• All published studies on PEG feeding in HIV-infected patients have used antibiotic prophylaxis 1
• Despite higher rates of local infection in immunocompromised patients, severe complications are not more frequent when prophylaxis is administered 1

Critical Timing and Administration Details

• Administer antibiotics within 30-60 minutes before the procedure to ensure adequate tissue levels at the time of bacterial contamination 1
• The patient should be fasting for 8 hours prior to the procedure 1
• An indwelling venous catheter should be placed for antibiotic administration 1
• Single-dose prophylaxis is sufficient; multiple doses or prolonged courses are not necessary and provide no additional benefit 1

Common Pitfalls to Avoid

• Do not delay antibiotic administration beyond one hour before the procedure, as tissue levels may be inadequate 1
• Do not omit prophylaxis even in low-risk patients, as the evidence supports universal prophylaxis for PEG placement 1
• Do not use narrow-spectrum antibiotics that lack anaerobic coverage, as mixed aerobic-anaerobic flora can cause peristomal infections 1, 3
• Do not continue antibiotics postoperatively unless there is documented infection, as this promotes resistance without additional benefit 1

Postprocedural Infection Prevention

• Ensure proper tension of the external fixation plate overnight with low traction to avoid excessive pressure 1
• Use sterile Y-compress dressings under the external fixation plate to prevent moist cavity formation 1, 4
• Cleanse and renew dressings initially on a daily basis, then every 2-3 days 1
• Allow sufficient free movement of the tube (≥5mm) after the first dressing change 1