A multidisciplinary approach to reducing percutaneous endoscopic gastrostomy tube site infections within 30 days of placement

Published Date: 01st April 2022

Publication Authors: Roberts S, Clark K, Theis V, Tyrer J

Abstract
Percutaneous endoscopic gastrostomy (PEG) site infection is a known complication of PEG tube placement. Whilst difficult to know the true incidence of PEG site infections as rates vary1, it is thought that infection rates fluctuate between 5% and 25%2. Thirty day infection rates form part of an annual audit of PEG insertions at a large District General Hospital (DGH). The mean infection rate from 2018-2019 was 11.8%. In 2020, it was concerning to note that the infection rate rose to 41% (16 out of 39 cases) which led to a multidisciplinary process review. Mean time to infection was 6.5 days post insertion (range 3-16 days). Of the 16 cases, 6 were polymicrobial. Organisms included: Staphylococcus aureus (11), mixed anaerobes (4), Group B Streptococcus (3), Group C Streptococcus (2), Streptococcus pneumoniae (1) and Streptococcus milleri (1). All those who had a PEG placed were confused and incontinent, 2 had coexisting diabetes and 1 was receiving high dose corticosteroids, all of which put them at higher risk of developing PEG site infection. Local antimicrobial policy recommends IV gentamycin at 3mg/kg body weight pre-procedure and it was noted that in 4 cases, inadequate dosing was a contributory factor. There was no operator trend identified. It was highlighted that in 2020, the antimicrobial of choice pre-procedure was changed to Gentamycin 3mg/kg body weight from IV Teicoplainin 400mg, which had been used the preceding 2 years. The Nutrition team, in collaboration with the Microbiology department, agreed to a change in policy, reverting to IV Teicoplainin 800mg pre-procedure alongside the addition of chlorhexidine body washes 48 hours pre-procedure and 72 hours post-PEG insertion. The infection prevention nurse (IPN) team observed a PEG insertion to ensure that the procedure was carried out appropriately with surgical ANTT and performed an environmental endoscopy visit. The IPN team also visited high usage wards to perform environmental reviews and to follow up patients to monitor appropriate after care. The PEG pathway was updated to reflect the amendments and ensure that each stage of the process (pre, during and post procedure) was completed. An interim 3 month audit was performed after the relevant changes, which demonstrated success and 5/5 PEGs placed between Jan 2021 and April 2021 had no PEG site infections. PEG site infections are a relatively common complication and regular audit is recommended to monitor practice. When infection rates increase, it is important to look at every process, identify any root causes and make the required changes to reduce the incidences as far as is reasonably practicable. The PEG pathway is an excellent way of ensuring that all stages of PEG care are clearly identified and streamlined for all those working with this patient group, to deliver the highest standards of care and reduce the risk of complication. Working together with various members of the MDT (microbiology, endoscopy, infection control, and ward staff) is crucial to reducing infections and optimising the care and management of PEG tubes. References 1. Westaby D, Young A, O'Toole P, Smith G, Sanders D. The provision of a percutaneously placed enteral tube feeding service. Gut. 2010;59(12):1592-1605. 2. Rahnemai-Azar A. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management. World Journal of Gastroenterology. 2014;20(24):7739.

Roberts, S; Clark, K; Theis, V; Tyrer, J. (2022). A multidisciplinary approach to reducing percutaneous endoscopic gastrostomy tube site infections within 30 days of placement. Clinical Nutrition ESPEN. 48, p.495. [Online]. Available at: https://doi.org/10.1016/j.clnesp.2022.02.048 [Accessed 16 September 2022]

 

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