Secondary Logo

Journal Logo

Original Articles: Gastroenterology

Do Antibiotics Reduce the Incidence of Infections After Percutaneous Endoscopic Gastrostomy Placement in Children?

Krom, Hilde; van den Hoek, Charlotte M.W.; Benninga, Marc A.; Delemarre, Eveline A.; de Jong, Justin R.; Koot, Bart G.P.; Tabbers, Merit M.; Voogt, Heleen; Kindermann, Angelika

Author Information
Journal of Pediatric Gastroenterology and Nutrition: July 2020 - Volume 71 - Issue 1 - p 23-28
doi: 10.1097/MPG.0000000000002709
  • Free

Abstract

What Is Known/What Is New

What Is Known

  • Percutaneous endoscopic gastrostomy provides a long-term solution in maintaining nutritional intake in children and adults with tube feeding dependency.
  • Recommendations to use prophylactic antibiotic treatment to reduce wound infections are mainly based on adult studies; previous pediatric studies challenged the efficacy in children.

What Is New

  • This study confirms that prophylactic antibiotic treatment does not seem to reduce wound infection in children, and might even increase overgranulation.
  • Prophylactic antibiotic treatment might be beneficial in children receiving a percutaneous endoscopic gastrostomy with respect to the occurrence of fever, leakage, and duration of hospital admission.

Tube feeding maintains energy and nutritional intake in children with an inadequate oral intake, wasting, or stunting in varying clinical entities (1). It can also be used to facilitate fluids and medication delivery (2). If tube feeding is required for longer periods, a gastrostomy should be considered, being beneficial compared with nasogastric tubes with regard to tube displacement, aspiration, irritation, ear nose throat (ENT) complications, cosmetics, and oral skill development (1,3,4). In 1980, Gauderer et al.(5) introduced the percutaneous endoscopic gastrostomy (PEG), a widely used relatively quick and technically simple procedure. In 11% of pediatric patients, however, at least 1 complication occurs within 5 years after the PEG procedure (3). Minor complications include blockage, dislodgement, degradation and removal of the tube, leakage, transient gastroparesis, ulceration in the gastric wall, overgranulation, and wound infection. Major complications include amongst others perforation and fistula in the gastro-esophageal region, aspiration pneumonia, buried bumper, bleeding, and systemic infection (3). Minor complications, such as wound infection (4–30%) are common, but major complications occur less frequently.

A Cochrane review with pooled analysis of 12 randomized controlled trials (RCTs) evaluating the use of prophylactic antibiotic treatment (ABT) during PEG tube placement in adults, showed a reduced infection rate in patients receiving prophylactic ABT (intravenous cephalosporines) (3,6–19). On the basis of this review, an ESPGHAN position paper recommends prophylactic ABT before PEG placement (3). In clinical practice, prophylactic ABT are widely used worldwide as standard of care in children (3,20–24). Studies, however, in children are lacking to support this recommendation.

Therefore, the aim of this study was to compare wound infection and the occurrence of other complications between children undergoing PEG placement with and without prophylactic ABT.

METHODS

Participants and Procedure

Data of children 0 to 18 years old undergoing a PEG procedure at the Emma Children's Hospital, a tertiary care center in Amsterdam, the Netherlands, between January 2000 and May 2013 were collected retrospectively by reviewing medical charts (September 2013). Children who underwent a laparoscopic gastrostomy were excluded.

Percutaneous Endoscopic Gastrostomy Procedure

Before tube placement, a pediatric gastroenterologist evaluated all patients during an outpatient visit or if the child was admitted for another reason in clinic. History and physical examination were carried out to assess indications and contraindications for PEG placement. Contraindications for PEG-placement were severe scoliosis, esophageal atresia, portal hypertension, hepatomegaly, thrombocytopenia, coagulation disorders, and massive ascites. Patients and parents were informed about the procedure and possible side-effects and complications. Informed consent was given by parents. Patients were admitted to the hospital 1 day before the PEG procedure. The procedure took place under general anesthesia and was performed by a pediatric gastroenterologist, assisted by an endoscopy assistant and pediatric surgeon. Freka (Fresenius, Oberursel, Germany) 15Fr PEG tubes were placed, using the pull through technique (5). Before March 2010, no prophylactic ABT was given unless there was a clinical indication, such as endocarditis prophylaxis. Due to assumed benefits, our PEG protocol changed in March 2010 and patients were receiving a prophylactic broad-spectrum antibiotic (50 mg/kg Cefazoline intravenously) 1 hour before placement. After recovery, a small amount of water was administered via the PEG tube and if tolerated, feeding was slowly started after 4 hours. Parents were educated to take care of the PEG and the child was discharged if tube feeding was tolerated.

After 1 week, all children were routinely seen and re-evaluated by a nurse specialized in PEG tube care. Furthermore, parents were instructed to contact the nurse or their pediatric gastroenterologist in case of problems or complications, such as irritation by leakage, overgranulation, infection gastrostomy, and problems with stoma care (including pushing/pulling and rotating).

Measures

The collected data included age, sex, underlying diseases, indication of PEG placement, prophylactic ABT per PEG protocol, ABT for other reasons (such as immunodeficiency or endocarditis prophylaxis), size of tube, and admission days in the hospital. Furthermore, we collected data regarding complications during or after PEG procedure (including fever, overgranulation, leakage, wound infection, peritonitis/perforation, buried bumper, bleeding, and mortality). The occurrence of fever and wound infection were assessed at different time frames: at days 1 and 2; at days 3 to 7; at days 8 to 28; at months 2 to 3 and 5; and after 3 months.

Definitions

Fever was defined as having a body temperature higher than 38.5 °C. Wound infection was defined as swelling and/or redness that was treated with local or systemic ABT.

Leakage was defined as leakage of feed or gastric content from gastrostomy along the gastrostomy tube.

Overgranulation was defined as red/pink tissue at the stomal border that expanded above the surrounding skin, which did not improve towards healing.

Statistical Analysis

Data were entered into the Statistical Package for Social Science (IBM SPSS Statistics) version 25. Normality of continuous variables was tested by the Shapiro-Wilk test in addition to eye balling. Differences between groups (patients receiving prophylactic ABT following the new protocol vs patients not receiving prophylactic ABT following the old protocol; and patients receiving ABT for any reason vs patients receiving no ABT at all) for binary variables were analyzed using Fischer exact tests, and for age (which was not normally distributed) using the Mann-Whitney test. A value of P < 0.05 (two-sided) was considered to be significant. Complication rates were generated on a bootstrapped 95% confidence interval (Bca CI95%) based on 1000 samples.

Medical Ethics

The Medical Ethical Committee of the Amsterdam UMC confirmed that the Medical Research Involving Human Subjects Act (WMO) did not apply to our study.

RESULTS

In total, 297 patients (53% boys) with a median age of 2.9 (interquartile range [IQR] 1.2–7.0) years were included in the study. Patient characteristics are shown in Table 1. In total, 78 (26%) children received and 219 (74%) did not receive prophylactic ABT per PEG protocol. The most common underlying disorders were neurological disorders (25.9%), metabolic disorders (19.5%), and genetic syndromes (18.5%). Long-lasting feeding problems (90.6%) were the main indication for PEG placement in both groups. Twenty-one patients underwent PEG placement for the administration of medication (laxatives for constipation [n = 18], antiepileptics [n = 1], antiretroviral therapy for HIV [n = 1], and multiple drugs for hypoaldosteronism [n = 1]).

TABLE 1
TABLE 1:
Patients characteristics

Patients stayed in the hospital for a median of 3 (IQR 3–6) days. Complications were reported in 119 children (40.1%) (Table 2). In 8 (2.7%) children, complications occurred during the procedure, including colon perforation requiring surgery (n = 2), failure to obtain sufficient transillumination resulting in abortion of the procedure (n = 1), gastric needle dislocation with small defect requiring a second puncture (n = 5). Postprocedural complications were reported in 115 (38.7%) children. Sixty (20.2%) patients were treated with local or systemic ABT because of swelling and/or redness and were, therefore, diagnosed with wound infection (n = 60, 20.2%), which was the most common complication, occurring within the first week after placement in 50% of the children. Patients with wound infection had significantly more often leakage (n = 11/60, 18.3%) than patients without (n = 9/237, 3.8%) (P = 0.000). Bleeding and mortality were not seen.

TABLE 2
TABLE 2:
Complications during and after percutaneous endoscopic gastrostomy procedure

The total number of complications, complications during PEG placement and postprocedural complications did not differ significantly between the patients receiving prophylactic ABT per PEG protocol and those without ABT (Table 3). The number of wound infections did not differ significantly between the 2 groups as well. Fever and leakage were less common in patients receiving prophylactic ABT. Overgranulation was seen significantly more frequent in patients treated with prophylactic ABT. The admission duration in the hospital of patients without prophylactic ABT was significantly longer.

TABLE 3
TABLE 3:
Complications of percutaneous endoscopic gastrostomy procedure

Thirty-seven (16.9%) children did receive perioperative ABT because of clinical indications, such as prophylaxis for endocarditis, urinary tract infection, and respiratory infections. Table 4 shows subanalyses comparing the group of patients with overall perioperative ABT use (because of PEG protocol and for clinical indication) with patients not receiving any ABT. The duration of hospital admission was significantly longer in patients without ABT (4 vs 3 days). The total number of complications, complications during the procedure, and posprocedural complications did not differ significantly between groups. There were no statistically significant differences in wound infection rate between groups. Overgranulation was more common in patients receiving any ABT.

TABLE 4
TABLE 4:
Subanalyses with overall perioperative antibiotic treatment

DISCUSSION

This retrospective study shows that wound infection rates are similar in patients receiving prophylactic ABT before PEG placement and those not receiving ABT. Fever and stoma leakage occurred significantly less frequently in patients with prophylactic ABT per PEG protocol compared with those without. The duration of hospital admittance was significantly shorter in patients receiving ABT per PEG protocol or for any reason compared with those without. Overgranulation, however, occurred more frequently in patients receiving prophylactic ABT per PEG protocol or receiving ABT for any reason, compared with those without.

In contrast to the Cochrane review describing successful prophylactic ABT in adults undergoing PEG placement, a recent published RCT in adults did not find significant differences regarding infection rates between patients receiving or not receiving prophylactic ABT (25). To date, only few studies were published assessing prophylactic ABT for PEG procedures in children. A small RCT, only published as an abstract, including 49 children showed that children with prophylactic ABT (n = 24, median age 2.3 years) had a significantly lower peristomal infection rate compared with those without (n = 25, median age 4.8 years) (8% vs 32%) (26). Results from other pediatric studies, however, were in line with the latter study in adults. Four small (n = 129, n = 103, n = 98, n = 27) retrospective studies including young children (median age 1.3–2.9 years) found no significant differences in occurrence of infections between patients with and without prophylactic ABT (27–30). In accordance, a small prospective observational study including 58 patients (ranging from 6 weeks to 45 years of age) and a larger multicenter prospective observational study including 239 patients (median age 8.1 years) neither found a significant difference in infection rate between patients receiving and not receiving ABT (31,32). Also no differences were found regarding infection rate comparing a single dose intravenous ceftriaxone to dual (intravenous ceftriaxone and metronidazole) 48-hour prophylactic ABT in 32 consecutively allocated children undergoing a PEG procedure (33).

In contrast to studies in adults, the above-mentioned pediatric studies suggest that the use of prophylactic ABT in children does not reduce infection rate. Different population characteristics might be an explanation for these different results. In the majority of children, a neurological disorder is the reason for PEG placement (21–24,29,32,34–38), whereas in adults, malignancies and diabetes mellitus are the main reasons for PEG placement. Immunosuppression and higher age make adults more prone to infection (27,28).

ABT may lead to adverse events, organism resistance development, and increased health care costs (33). Therefore, prophylactic ABT should only be provided if beneficial. Pediatric patients with immunodeficiency, congenital heart disease, ventriculoperitoneal shunt or on peritoneal dialysis are at risk for severe infections, and should therefore, receive prophylactic ABT (28). Pediatric studies assessing prophylactic ABT for PEG procedures are warranted to support recommendations in general pediatric guidelines.

Our data suggest, that the use of prophylactic ABT may have led to a shorter hospital stay. On the other hand, less frequent leakage and fever might also play a role regarding a shorter hospital stay in patients receiving prophylactic ABT per PEG protocol. Engelmann found a significant difference regarding mean body temperature between patients with and without prophylactic ABT (37.9 and 38.3 °C, respectively (P = 0.02), but infection rate defined as fever (temperature >39 °C) or increased CRP did not differ (28). During the years, there might have been a tendency to feed faster (without clear changes of protocol) and also recovering time after anesthesia might have become shorter (39).

Overgranulation occurred more frequently in our patients receiving ABT. We did not find other studies assessing the association between overgranulation and ABT. Interestingly, Fascetti-Leon et al showed that prophylactic ABT was an independent risk factor for complications within 12 months (multivariate analysis, P = 0.003, odds ratio [OR] 2.587, CI 1.372–4.878) and overgranulation was the most common complication at 12 months (32). Overgranulation is thought to be caused by a foreign body disrupting the healing process because of an inflammatory response (40). Intuitively, one would hypothesize that overgranulation occurs less often in patients receiving prophylactic ABT. Antibiotics, however, also change the microbiome, which also plays a role in mucosal wound healing (41,42). We, therefore, speculate that the disturbed microbiome might play a role in overgranulation. In addition, bacteria might easily enter the broken skin-barrier because of the foreign body creating an inflammatory response. However, this hypothesis should be further analyzed and elucidated.

Strengths and Limitations of the Study

Compared with other pediatric studies assessing prophylactic ABT in children undergoing PEG placement, this study included the largest group of children (26–33). The study covered patients from a 12.5-year timeframe. Data were collected thoroughly and described in detail. A shorter hospital stay in children undergoing PEG placement receiving prophylactic ABT was described for the first time. Some limitations, however, have to be considered. The major limitation is the retrospective design of the study, which may have led to bias by lack of standardization and risk of missing complications. In addition, differences in patient characteristics of both groups and the different time periods might also have resulted in selection bias. We cannot rule out, that these different time periods (without prophylactic ABT before 2010 and with prophylactic ABT since 2010) may have contributed to differences between groups. Therefore, causality of antibiotic prophylaxis and complications and other findings, such as duration of hospital stay cannot be confirmed and should be studied by prospective RCTs in the future.

CONCLUSIONS

This study suggests that prophylactic ABT does not seem to be advantageous with respect to wound infection. It might be advantageous with respect to fever, leakage, and duration of hospital admission but seems to be disadvantageous regarding overgranulation.

These results could open the discussion regarding prophylactic ABT before PEG placement again. Therefore, a large well-designed prospective multicenter international pediatric RCT assessing infection rate in patients (0–18 years of age) with and without prophylactic ABT should be performed to confirm these conclusions. Medical background, hospital duration, and complications should be clearly defined and followed-up prospectively. Cost-effectiveness should also be taken into account.

REFERENCES

1. Braegger C, Decsi T, Dias JA, et al. ESPGHAN Committee on Nutrition. Practical approach to paediatric enteral nutrition: a comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr 2010; 51:110–122.
2. Krom H, van Zundert SMC, Otten MGM, et al. Prevalence and side effects of pediatric home tube feeding. Clin Nutr 2018; 38:234–239.
3. Heuschkel RB, Gottrand F, Devarajan K, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. ESPGHAN position paper on management of percutaneous endoscopic gastrostomy in children and adolescents. J Pediatr Gastroenterol Nutr 2015; 60:131–141.
4. Kim J, Lee M, Kim SC, et al. Comparison of percutaneous endoscopic gastrostomy and surgical gastrostomy in severely handicapped children. Pediatr Gastroenterol Hepatol Nutr 2017; 20:27–33.
5. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980; 15:872–875.
6. Lipp A, Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy. Cochrane Database Syst Rev 2013; (11):CD005571.
7. Ahmad I, Mouncher A, Abdoolah A, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy--a prospective, randomised, double-blind trial. Aliment Pharmacol Ther 2003; 18:209–215.
8. Akkersdijk WL, van Bergeijk JD, van Egmond T, et al. Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis. Endoscopy 1995; 27:313–316.
9. Blomberg J, Lagergren P, Martin L, et al. Novel approach to antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): randomised controlled trial. BMJ 2010; 341:c3115.
10. Dormann AJ, Wigginghaus B, Risius H, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG)--results from a prospective randomized multicenter trial. Z Gastroenterol 2000; 38:229–234.
11. Gossner L, Keymling J, Hahn EG, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial. Endoscopy 1999; 31:119–124.
12. Jain NK, Larson DE, Schroeder KW, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blind clinical trial. Ann Intern Med 1987; 107:824–828.
13. Jonas SK, Neimark S, Panwalker AP. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1985; 80:438–441.
14. Panigrahi H, Shreeve DR, Tan WC, et al. Role of antibiotic prophylaxis for wound infection in percutaneous endoscopic gastrostomy (PEG): result of a prospective double-blind randomized trial. J Hosp Infect 2002; 50:312–315.
15. Preclik G, Grune S, Leser HG, et al. Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy. BMJ 1999; 319:881–884.
16. Saadeddin A, Freshwater DA, Fisher NC, et al. Antibiotic prophylaxis for percutaneous endoscopic gastrostomy for non-malignant conditions: a double-blind prospective randomized controlled trial. Aliment Pharmacol Ther 2005; 22:565–570.
17. Shashi V, Pena LD, Kim K, et al. De novo truncating variants in ASXL2 are associated with a unique and recognizable clinical phenotype. Am J Hum Genet 2017; 99:991–999. Erratum appears in Am J Hum Gen 2017; 100:179.
18. Sturgis TM, Yancy W, Cole JC, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1996; 91:2301–2304.
19. Radhakrishnan NV, Shenoy AH, Cartmill I, et al. Addition of local antiseptic spray to parenteral antibiotic regimen reduces the incidence of stomal infection following percutaneous endoscopic gastrostomy: a randomized controlled trial. Eur J Gastroenterol Hepatol 2006; 18:1279–1284.
20. Vervloessem D, van Leersum F, Boer D, et al. Percutaneous endoscopic gastrostomy (PEG) in children is not a minor procedure: risk factors for major complications. Semin Pediatr Surg 2009; 18:93–97.
21. Wu FY, Wu JF, Ni YH. Long-term outcome after percutaneous endoscopic gastrostomy in children. Pediatr Neonatol 2013; 54:326–329.
22. Chang PF, Ni YH, Chang MH. Percutaneous endoscopic gastrostomy to set up a long-term enteral feeding route in children: an encouraging result. Pediatr Surg Int 2003; 19:283–285.
23. Fortunato JE, Troy AL, Cuffari C, et al. Outcome after percutaneous endoscopic gastrostomy in children and young adults. J Pediatr Gastroenterol Nutr 2010; 50:390–393.
24. McSweeney ME, Jiang H, Deutsch AJ, et al. Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement. J Pediatr Gastroenterol Nutr 2013; 57:663–667.
25. Adachi Y, Akino K, Mita H, et al. Systemic prophylactic antibiotics for the modified introducer method for percutaneous endoscopic gastrostomy: a prospective, randomized, double-blind study. J Clin Gastroenterol 2016; 50:727–732.
26. Wilson ML, Paxton CE, Hoole D, et al. Antibiotic prophylaxis significantly reduces infection rates at paediatric percutaneous endoscopic gastrostomy (PEG) tube insertion: results of an RCT. Gastroenterology 2008; 134: (Suppl 1): A-81–A-82.
27. van Els AL, van Driel JJ, Kneepkens CM, et al. Antibiotic prophylaxis does not reduce the infection rate following percutaneous endoscopic gastrostomy in infants and children. Acta Pædiatr 2017; 106:801–805.
28. Engelmann G, Wenning D, Fertig E, et al. Antibiotic prophylaxis in the management of percutaneous endoscopic gastrostomy in infants and children. Pediatr Int 2015; 57:295–298.
29. Viktorsdottir MB, Oskarsson K, Gunnarsdottir A, et al. Percutaneous endoscopic gastrostomy in children: a population-based study from iceland, 1999–2010. J Laparoendosc Adv Surg Tech A 2015; 25:248–251.
30. von Schnakenburg C, Feneberg R, Plank C, et al. Percutaneous endoscopic gastrostomy in children on peritoneal dialysis. Perit Dial Int 2006; 26:69–77.
31. Mathus-Vliegen EM, Koning H, Taminiau JA, et al. Percutaneous endoscopic gastrostomy and gastrojejunostomy in psychomotor retarded subjects: a follow-up covering 106 patient years. J Pediatr Gastroenterol Nutr 2001; 33:488–494.
32. Fascetti-Leon F, Gamba P, Dall’Oglio L, et al. Complications of percutaneous endoscopic gastrostomy in children: results of an Italian multicenter observational study. Dig Liver Dis 2012; 44:655–659.
33. Rawat D, Srivistava A, Thomson M. Antibody prophylaxis for children undergoing percutaneous endoscopic gastrostomy. J Pediatr Gastroenterol Nutr 2005; 40:234–235.
34. Dehghani SM, Haghighat M, Nematollahi F, et al. Percutaneous endoscopic gastrostomy in children: a single center study at tertiary hospital Iran. Rev Gastroenterol Peru 2018; 38:125–127.
35. Dookhoo L, Mahant S, Parra DA, et al. Peritonitis following percutaneous gastrostomy tube insertions in children. Pediatr Radiol 2016; 46:1444–1450.
36. Islek A, Sayar E, Yilmaz A, et al. Percutaneous endoscopic gastrostomy in children: is early feeding safe? J Pediatr Gastroenterol Nutr 2013; 57:659–662.
37. Casswall T, Backstrom B, Drapinski M, et al. Help to children and adolescents with malnutrition or eating disorders. Percutaneous endoscopic gastrostomy with button: simple, safe and cost-effective. Lakartidningen 2000; 97:688–691.
38. Khattak IU, Kimber C, Kiely EM, et al. Percutaneous endoscopic gastrostomy in paediatric practice: complications and outcome. J Pediatr Surg 1998; 33:67–72.
39. Peck J, Mills K, Dey A, et al. Comparison of tolerance and complication rates between early and delayed feeding after percutaneous endoscopic gastrostomy placement in children. J Pediatr Gastroenterol Nutr 2020; 70:55–58.
40. Rollins H. Hypergranulation tissue at gastrostomy sites. J Wound Care 2000; 9:127–129.
41. Blaser MJ. Antibiotic use and its consequences for the normal microbiome. Science 2016; 352:544–545.
42. Alam A, Neish A. Role of gut microbiota in intestinal wound healing and barrier function. Tissue Barriers 2018; 6:1539595.
Keywords:

children; percutaneous endoscopic gastrostomy; prophylactic antibiotic treatment; tube feeding

Copyright © 2020 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition