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An overtube is not required for reducing post-PEG peristomal infection
Letters to the Editor
An overtube is not required for reducing post-PEG peristomal infection To the Editor: Maetani et al1 have shown that the use of an overtube decreases the rate of peristomal infection after placement of PEG. Unfortunately, this may convey a message that an overtube is a desirable accessory for this procedure. As the investigators themselves have acknowledged and as experience with its use for variceal ligation has shown, overtube placement is a callous process, associated with significant complications. A more humane alternative is required. The infection rate (33%) in patients treated without an overtube in the study by Maetani et al1 is high. Earlier studies have reported rates that ranged from 3% to 30%.2,3 In our center, only 3 of 62 patients (4.8%) who had PEG placement in the past 18 months developed peristomal infection during their hospital stay. All 3 were infected by extended spectrum beta lactamases–producing gram-negative organisms. This was in conformity with the organisms most commonly isolated in our institution and particularly in our intensive care unit (ICU). The rate of methicillin resistant Staphylococcus aureus colonization in our ICU patients is low. We do not use an overtube but routinely use chlorhexidine as a preprocedure oral antiseptic. If the patient already was on an antibiotic for another indication, we continued its use. If not, we administered a single dose of a third-generation cephalosporin 30 minutes before the procedure. The choice of prophylactic antibiotic should be based on the sensitivity of the organisms commonly prevalent in a hospital. A meta-analysis has confirmed that one dose of a broad-spectrum antibiotic given half an hour before the procedure is sufficient.4 Most studies used a thirdgeneration cephalosporin. Incidentally, one study reported a low efficacy of cefazolin (the antibiotic used by Maetani et al1) as a prophylactic antibiotic.5 We, therefore, feel that an oral antiseptic could be an effective way of reducing peristomal infection and should be preferred to the use of an overtube. An appropriate antibiotic given prophylactically is adequate.
2. Lockett MA, Templeton ML, Byrne TK, et al. Percutaneous endoscopic gastrostomy complications in a tertiary-care center. Am Surg 2002;68: 117-20. 3. Aschl G, Kirchgatterer A, Allinger S, et al. Indications and complications of percutaneous endoscopic gastrostomy. Wien Klin Wochenschr 2003; 115:115-20. 4. Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol 2000;95:3133-6. 5. Sturgis TM, Yancy W, Cole JC, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1996;91:2301-4. doi:10.1016/j.gie.2005.07.001
Response:
1. Maetani I, Yasuda M, Seiki M, et al. Efficacy of an overtube for reducing the risk of peristomal infection after PEG placement: a prospective, randomized comparison study. Gastrointest Endosc 2005;61:522-7.
We thank Mandot and colleagues for their interest in our article.1 Currently, an overtube is widely used as a useful accessory device of the endoscope for some purposes, not only in endoscopic variceal ligation but also in the retrieval of a foreign body.2 Endoscopists probably are familiar with the overtube, which usually is equipped in most endoscopy units. Although there have been some reports on overtube-related complications, the latest models of an overtube with high flexibility and a tapered tip are designed to address the inadequacies of traditional overtube. Chang and Yen2 indicated that the overtube is the same as the one used in our series and is quite flexible and easy to pass through the oropharynx. Furthermore, an adequate insertion technique seems beneficial to avoid severe complications. We have not encountered a significant complication, e.g., mucosal tear of the esophagus, in hundreds of series of procedures: PEG, EVL, and retrieval of foreign bodies. Suzuki et al3 demonstrated an efficacy of the dedicated overtube in reducing the rate of peristomal infection after PEG placement (1% vs. 34.8%, p ! 0.001), which is comparable with our outcome.1 The rate of peristomal wound infection varies between 3% and 30%. Some investigators reported a high incidence of peristomal infection. Preclik et al4 reported that the wound infection rate was 65% in the placebo group and was 20% in the antibiotic prophylaxis group. Others reported that PEG-site infection was found in 35%, even with several days of antibiotic administration after PEG placement.3 The fundamental rate of PEG-site infection may, presumably, depend on the following factors: patient selection, prior antibiotics given for preexisting illness,5 the institution, and the colonization rate with resistant organisms. Antibiotic prophylaxis is believed to be effective for preventing peristomal infection. However, British researchers reported that two thirds of the patients who received PEG placement were colonized with methicillin resistant Staphylococcus aureus (MRSA).6 Also, Chaudary et al7 showed that MRSA has emerged as a major cause of PEG-site infections in the United States. This is apparently observed in
www.giejournal.org
Volume 62, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 821
Ameet Mandot, MD Tarun Gupta, DNB Philip Abraham, MD, DNB, FCPS Anand G. Joshi, MD Devendra C. Desai, MD, DNB Gastroenterology Section Department of Medicine P D Hinduja National Hospital Mumbai, India REFERENCES
An overtube is not required for reducing post-PEG peristomal infection To the Editor: Maetani et al1 have shown that the use of an overtube decreases the rate of peristomal infection after placement of PEG. Unfortunately, this may convey a message that an overtube is a desirable accessory for this procedure. As the investigators themselves have acknowledged and as experience with its use for variceal ligation has shown, overtube placement is a callous process, associated with significant complications. A more humane alternative is required. The infection rate (33%) in patients treated without an overtube in the study by Maetani et al1 is high. Earlier studies have reported rates that ranged from 3% to 30%.2,3 In our center, only 3 of 62 patients (4.8%) who had PEG placement in the past 18 months developed peristomal infection during their hospital stay. All 3 were infected by extended spectrum beta lactamases–producing gram-negative organisms. This was in conformity with the organisms most commonly isolated in our institution and particularly in our intensive care unit (ICU). The rate of methicillin resistant Staphylococcus aureus colonization in our ICU patients is low. We do not use an overtube but routinely use chlorhexidine as a preprocedure oral antiseptic. If the patient already was on an antibiotic for another indication, we continued its use. If not, we administered a single dose of a third-generation cephalosporin 30 minutes before the procedure. The choice of prophylactic antibiotic should be based on the sensitivity of the organisms commonly prevalent in a hospital. A meta-analysis has confirmed that one dose of a broad-spectrum antibiotic given half an hour before the procedure is sufficient.4 Most studies used a thirdgeneration cephalosporin. Incidentally, one study reported a low efficacy of cefazolin (the antibiotic used by Maetani et al1) as a prophylactic antibiotic.5 We, therefore, feel that an oral antiseptic could be an effective way of reducing peristomal infection and should be preferred to the use of an overtube. An appropriate antibiotic given prophylactically is adequate.
2. Lockett MA, Templeton ML, Byrne TK, et al. Percutaneous endoscopic gastrostomy complications in a tertiary-care center. Am Surg 2002;68: 117-20. 3. Aschl G, Kirchgatterer A, Allinger S, et al. Indications and complications of percutaneous endoscopic gastrostomy. Wien Klin Wochenschr 2003; 115:115-20. 4. Sharma VK, Howden CW. Meta-analysis of randomized, controlled trials of antibiotic prophylaxis before percutaneous endoscopic gastrostomy. Am J Gastroenterol 2000;95:3133-6. 5. Sturgis TM, Yancy W, Cole JC, et al. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol 1996;91:2301-4. doi:10.1016/j.gie.2005.07.001
Response:
1. Maetani I, Yasuda M, Seiki M, et al. Efficacy of an overtube for reducing the risk of peristomal infection after PEG placement: a prospective, randomized comparison study. Gastrointest Endosc 2005;61:522-7.
We thank Mandot and colleagues for their interest in our article.1 Currently, an overtube is widely used as a useful accessory device of the endoscope for some purposes, not only in endoscopic variceal ligation but also in the retrieval of a foreign body.2 Endoscopists probably are familiar with the overtube, which usually is equipped in most endoscopy units. Although there have been some reports on overtube-related complications, the latest models of an overtube with high flexibility and a tapered tip are designed to address the inadequacies of traditional overtube. Chang and Yen2 indicated that the overtube is the same as the one used in our series and is quite flexible and easy to pass through the oropharynx. Furthermore, an adequate insertion technique seems beneficial to avoid severe complications. We have not encountered a significant complication, e.g., mucosal tear of the esophagus, in hundreds of series of procedures: PEG, EVL, and retrieval of foreign bodies. Suzuki et al3 demonstrated an efficacy of the dedicated overtube in reducing the rate of peristomal infection after PEG placement (1% vs. 34.8%, p ! 0.001), which is comparable with our outcome.1 The rate of peristomal wound infection varies between 3% and 30%. Some investigators reported a high incidence of peristomal infection. Preclik et al4 reported that the wound infection rate was 65% in the placebo group and was 20% in the antibiotic prophylaxis group. Others reported that PEG-site infection was found in 35%, even with several days of antibiotic administration after PEG placement.3 The fundamental rate of PEG-site infection may, presumably, depend on the following factors: patient selection, prior antibiotics given for preexisting illness,5 the institution, and the colonization rate with resistant organisms. Antibiotic prophylaxis is believed to be effective for preventing peristomal infection. However, British researchers reported that two thirds of the patients who received PEG placement were colonized with methicillin resistant Staphylococcus aureus (MRSA).6 Also, Chaudary et al7 showed that MRSA has emerged as a major cause of PEG-site infections in the United States. This is apparently observed in
www.giejournal.org
Volume 62, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 821
Ameet Mandot, MD Tarun Gupta, DNB Philip Abraham, MD, DNB, FCPS Anand G. Joshi, MD Devendra C. Desai, MD, DNB Gastroenterology Section Department of Medicine P D Hinduja National Hospital Mumbai, India REFERENCES