Treatment of Purulent Drainage Around a PEG Tube
For purulent drainage around a PEG tube, initiate systemic broad-spectrum antibiotics covering both skin flora (including MRSA) and gram-negative organisms, while simultaneously performing local wound care with antimicrobial cleansers and topical antimicrobial agents. 1
Initial Assessment and Diagnosis
- Obtain swabs for both bacterial and fungal cultures before starting antimicrobial therapy to guide subsequent treatment 1
- Distinguish true infection (erythema, purulent/malodorous exudate, fever, pain, loss of skin integrity) from minor irritation (<5mm reddening from tube movement) 1
- Risk factors increasing infection likelihood include diabetes, obesity, poor nutritional status, chronic corticosteroid therapy, and immunosuppressive therapy 1
Treatment Algorithm
Step 1: Local Wound Care
- Clean the affected skin at least once daily using an antimicrobial cleanser 2, 1
- Apply a topical antimicrobial agent to the entry site and surrounding tissue 1
- Use foam dressings rather than gauze to reduce skin maceration and lift drainage away from skin 2
- Apply barrier films, pastes, or creams containing zinc oxide for skin protection 2, 1
Step 2: Systemic Antibiotic Therapy
- If topical treatment fails to resolve the infection, add systemic broad-spectrum antibiotics immediately 1
- Tailor antibiotic selection based on culture results once available 1
Empiric Antibiotic Selection
The microbiology of PEG site infections has evolved significantly, with MRSA emerging as a major pathogen alongside gram-negative organisms:
- MRSA is now the predominant pathogen in many PEG site infections (found in 64% of culture-positive cases in one study), followed by pseudomonads and other gram-negatives 3
- Pseudomonas aeruginosa and coliforms are also common pathogens, particularly in healthcare settings 4
- Standard prophylactic regimens (cefotaxime, amoxicillin-clavulanic acid) do not adequately cover these resistant organisms 3, 4
For empiric therapy of established PEG site infection with purulent drainage:
- Piperacillin-tazobactam provides the most reliable broad-spectrum coverage for both gram-negative organisms (including Pseudomonas) and many gram-positive organisms 5
- Add vancomycin or linezolid for MRSA coverage if MRSA prevalence is high in your institution or the patient has risk factors 3
- Carbapenems (meropenem, imipenem) are alternative options for severe infections or multidrug-resistant organisms 5
Important Considerations and Pitfalls
- Avoid topical antibiotics as they promote antimicrobial resistance 1
- Standard prophylactic antibiotics (third-generation cephalosporins, fluoroquinolones) are often inadequate for treating established infections due to resistance patterns 5, 3
- Be aware of potential allergies to antimicrobial dressing components 1
- Silver dressings cannot be used during MRI procedures 1
- For concurrent fungal infections (often associated with leakage), use topical antifungal agents 2
Mechanical Factors Contributing to Infection
- Ensure proper tension between internal and external bolsters to avoid excessive pressure that can cause tissue breakdown 2, 1
- Prevent leakage which creates a moist environment promoting microbial growth 2, 1
- Verify balloon volume corresponds with manufacturer recommendations if using balloon-retained devices 2
- Stabilize the tube to minimize movement and friction that can worsen infection 2
When Conservative Management Fails
- If infection persists despite appropriate antibiotics and local care, consider tube replacement at a new location 2
- Severe complications like peritonitis require urgent surgical consultation and more aggressive management 5, 6
- Address any underlying excessive granulation tissue with silver nitrate cauterization or topical corticosteroids 2