Gastrostomy tube infections in a community hospital

Gastrostomy community

tube infections hospital

in a

Ethan C. T. Pien Karen E. Hume, RN, BN, CIC Francis D. Pien, MD, MPH Honolulu,

Hawaii

Backgrotnnd: Percutaneous gastric feeding tubes are becoming increasingly more common to provide nutrition in debilitated patients, while they decrease the risk of aspiration associated with nasogastric tubes. Methods: We reviewed infectious complications of 372 feeding gastrostomy tubes placed in a small urban community hospital over a recent period. Resdts: In our study there was an infection rate of 4.8%. Four serious infections occurred: two cases of peritonitis and two deep abscesses, but there were no infectious deaths. The most common infecting organisms were staphylococci, gram-negative bacteria, and yeast. Most infections required treatment with parenteral antibiotics, prolonging hospitalization. Two of 17 infected tubes required removal. ConcZztsion: Percutaneous gastrostomy tubes can produce life-threatening infections and deserve serious attention by services. These tubes should Protocols are needed for the early and as aggressively as Control 1996;24:353-8)

ICPs in only be care of possible

hospitals, long-term care facilities, and home care inserted if they extend meaningful life in patients. gastrostomy tubes, and infections must be treated as to avoid serious consequences. (AJIC Am J Infect

Use of feeding gastrostomy tubes is becoming increasingly common in patients with stroke and other debilitations, mainly to avoid aspiration and improve nutrition. This procedure is usually effective and considered to be of low risk.‘” Although these tubes were initially inserted surgically, most tubes are now placed percutaneously, either radiologically or via endoscopy.4-6 Previous reports describe infectious complications of gastrostomy tubes only briefly and are mainly from large academic hospitals. No studies, to our knowledge, have described in detail the microbiology of such infections. We present a large retrospective study of gastrostomy-related infections occurring at a small community hospital in Hawaii. METHODS

Straub Hospital is a 136-bed community hospital in Honolulu with stroke, neurosurgical, and cardiovascular services. We reviewed the records From the Honolulu. Reprint Hospital,

Department

of Medicine,

requests: Francis D. Pien, 888 S. King St., Honolulu,

Straub MD, MPH, HI 96813.

Copyright 0 1996 by the Association Control and Epidemiology, Inc. 0196.6553196

$5.00

+ 0

17146173377

Clinic

and

Straub

for Professionals

Hospital, Clinic

and

in Infection

of 372 patients who had feeding gastrostomy tubes inserted from September 1989 to July 1995. Approximately 95% of these tubes were placed percutaneously, and the remainder were placed surgically. Charts were reviewed for infections at all sites; and nosocomial infections that occurred or were present within 2 weeks of the gastrostomy tube site infection were studied in detail. A gastrostomy tube infection was considered superficial if purulent discharge was present, with tenderness, pain, and swelling of skin and superficial tissue. Infections were considered deep if deeper tissues were infected, often with fever; almost all patients with deep infections were examined by one of the authors (F.D.P.). Wounds were considered colonized if, in spite of positive culture results, no local treatment or antibiotic therapy was deemed necessary by treating physicians. Before 1994, gastrostomy infections were detected by retrospective chart review, whereas in 1994 to 1995, cases were found mainly by active infection control surveillance. Although we seriously considered a case control study, the small number of infected patients (IZ = 17) indicated that such analysis would not likely show statistical differences in epidemiologic characteristics between infected and noninfected patients. 353

AJIC

354

Pien, Hume,

Table

Pien

Organisms initially isolated gastrostomy sites

1.

infected

Organism

Miscellaneous gramnegative rods *Two patients

from No. of isolates

S. aureus Klebsiella sp. Corynebacterium sp. Pseudomonas aeruginosa Enterobacter cloacae Enterococcus fecalis Candida sp.

Streptococcus

October 1996

9* 5 4 3 2 2 2 4

sp.

were infected

with MRSA.

RESULTS

During our study period, 17 of 372 patients with gastrostomy tube insertions had a total of 18 local wound infections, for an infection rate of 4.8%. Seventeen infections developed in patients with percutaneous gastrostomy tubes, whereas one infection developed in a patient with a surgically placed tube. Two patients had development of infections after discharge and required hospital readmission. The other 15 patients had nosocomial wound infections develop 2 to 56 days after insertion, with a median time of 7 days. The age range of infected patients was 41 to 90 years, with a median of 75.6 years. There were 10 women and seven men. Seven infected patients were admitted initially for stroke, five were admitted for pneumonia, and five other patients were admitted for a surgical procedure. The major indications for gastrostomy tube insertion were for acute stroke (n = 7), subdural hematoma (n = 2), subarachnoid hemorrhage (n = 2), dementia (n = 4), residual hemiplegia (n = l), and postoperative malnutrition (n = 1). Table 1 shows the variety of infecting organisms. The most common isolate was Stuphylococctis aureus; after this bacterium, gram-negative organisms predominated, including Klebsiella sp.,

Pseudomonas sp., Enterobactersp., Morganellasp., Aeromonas sp., Serratia sp., and Citrobacter sp. Of 17 infected patients, 11 patients had other nosocomial infections within 2 weeks of their gastrostomy infection, including urinary tract (n = 6), respiratory (n = .5), and remote wound (n = 1); five of these infections were caused by the same organisms as found in the gastrostomy wound. Four major infectious complications occurred in our patients. Two patients had development of peritonitis, and two patients had development of

deep wound infections that required surgical drainage, one in the operating room and one at the bedside. Of 18 gastrostomy infections, 13 were treated with intravenous antibiotics, three received oral antibiotics, and two required only topical wound care. The parenterally treated patients received 240 days of intravenous antibiotics for their gastrostomy and other concurrent infections (average 18 days per patient). One patient had his infected gastrostomy tube removed in the operating room; one patient had her tube removed at the bedside. Eight of the 17 infected patients had their discharges delayed as a result of gastrostomy tube infections. Only three patients were discharged to their own home; the others went to nursing home facilities, except for one patient who died in the hospital of respiratory failure. DISCUSSION

This study describes the occurrence of gastrostomy tube infections in a small community hospital. Although none of our patients died of such infections, hospital stay was prolonged in almost half of these cases and involved lengthy courses of intravenous therapy in most patients. Table 2 shows results of previously published large (> 50 patients) percutaneous gastrostomy tube studies.‘“’ As can be seen, infection rates varied widely, with an average overall rate of 5.1%. These rates are similar to reported infection rates of surgically placed permanent feeding gastrostomy tubes, 1,3,4,25,28although some studies report more serious complications occurring with surgical gastrostomies.‘,3,5,9,‘3,17 Of major concern are serious infectious complications. Our study had two cases of peritonitis and deep wound abscesses that resolved with treatment. Table 2 includes eight deaths (0.19% of 4273 patients) directly attributed to wound infections progressing to peritonitis, deep abscess, or necrotizing fasciitis. In addition, Table 3 lists other case reports of serious percutaneous gastrostomy tube infections, with nine more deaths caused by necrotizing fasciitis, abscesses, peritonitis, and septic shock. 38-53Although most authors listed in Table 2 failed to describe their wound organisms, Table 3 lists some of the organisms that caused serious infections, including S. uureus, gram-negative bacteria, and Candida albicans. These organisms are similar to those that caused local wound infections identified in our study (Table 1). Although gastrostomy tube infections in our

AJIC Volume

Table

24,

Number

Pien, Hume, Pien

5

2. Previous

Author

percutaneous

gastrostomy

No. of successful procedures

tube

Infection rate (%)

Ponsky et aL7 Kirby et al.* Stern9 Mago et al.‘O Dye et al.” Larson et al.‘” Himal and Schumacheri Slezak and Kofoli4 Dietel et al,15

307 51 100 51 50 299 78 71 56

2.9 12 2.0 37 8.0 6.7 2.6 2.8 11

Sangster Granti

155 125

3.2 4.8

Foutch et aLi Ho et al.jg Steffes et al.‘O

113 133 103

0.88 0.75 9.7

Hollands et al.” Miller et al.22 Halkier et aLZ3 O’Keeffe et aIZ4 Stiegmann et al.*5 Chung and Schertze?

50 316 250 100 61 115

36 1.6 2.4 2.0 3.3 8.7

O’Dwyer et al.“’ Samii and Suguitar? Saini et al,2g Fay et aL30 Aisenberg et al.3’ Scott et aL3” Saunders et al.33 Gibson et al.34 Taylor et al.35

55 51 63 80 76 50 136 334 88

Grant36

595

1.8 5.9 3.2 5.0 2.6 8.0 0.74 3.3 27 “major” 60 “minor” 1.7

et alLi

Raha and Woodhouse Total

161 4273

infection

9.9 Fi

studies

with

Major infectious complications 0 1 1 1 0 2 0 0 0

at least

50 patients

each

infection-related deaths 0 0 I 0 0 0 0 0 0

Infecting bacteria

1 peritonitis 1 abscess 2 cellulitis with abscess formation 1 peritonitis 0 1 peritonitis 3 abscess 2 abscess 5 peritonitis 4 peritonitis 0 0 2 necrotizing fasciitis 1 myositis 1 peritonitis 0 1 peritonitis 0 0 0 0 0 N.D.

0 0

N.D. N.D. N.D. Staphylococcus sp. N.D. N.D. N.D. N.D. S. aureus, Streptococcus SP. N.D. N.D.

1 0 0 0 0 1 1 0 0 1 0 1 0 0 0 0 0 0 0 0

N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. N.D. ND N.D.

1 abscess 5 peritonitis 1 peritonitis 24 peritonitis 10 abscess 2 necrotizing 1 myositis

1 0 1 s

N.D. N.D. N.D.

peritonitis peritonitis abscess peritonitis

355

fasciitis

ND., Not described.

study did not lead to any deaths, they caused significant cost expenditures in antibiotics (mainly parenteral), physician care, and prolongation of hospitalization, as well as long-term placement difficulties, especially for patients infected by methicillin-resistant S. aureus (MRSA). Because most infections occurred in elderly patients receiving Medicare, our hospital bore these additional costs. The median time from insertion of the gastrostomy tube to the onset of nosocomial infection in our 15 patients was 7 days. This short period may

have been due to poor aseptic technique during insertion in radiology (M = 9 infections) and gastroenterology operating suites (n = 7 infections) or suboptimal wound care on hospital nursing units. The role of perioperative antibiotic prophylaxis is controversial, 1,16,22,55s6and its usefulness probably depends on the frequency of wound infection2’*55; we are unable to address this issue from our retrospective study. A technical review for tube feeding has recently been published,57 but more detailed procedures for gastrostomy tube placement and care are needed to reduce infec-

356 Table

Pien, Hume, Pien 3.

Additional

case

October

reports

of serious

Complication Author Cave

et al.38

Necrotizing

percutaneous

(single specified)

Necrotizing fasciitis Peristomal subcutaneous lntraabdominal abscess Necrotizing fasciitis

Korula

Necrotizing

fasciitis

Necrotizing

fasciitis

Martindale

et al.44

Haas et aI,” Ditesheim et al.46

Banerjee and Moore47 Pate1 et al.48 Apelgren and Zambos4’ Gillanders et aL5’ Wicks et aL5’ Finucane et aL5” Hull et aLs3

unless

fasciitis

Person and Brower3g Hogan et aL40 Kozarek et al.“’ Greif et aI.@ and Rich43

case

gastrostomy

associated

infection-related death 0

abscess

Necrotizing fasciitis Peritonitis (2) Septic shock Abdominal wall abscess Subcutaneous abscess Necrotizing fasciitis (2) Peritonitis Cellulitis Peritonitis Deep wound infection Peritonitis Peritonitis Peritonitis

0 0 0

1 0 2 1

AJIC 1996

infections

Infecting

organisms

Proteus mirabilis, Klebsiella sp., Streptococcus sp. S. aureus, Enterococcus sp. N.D. N.D. Enterococcus sp., 5’. aureus, Staphy/ococcus epidermidis Klebsiella pneumoniae, Streptococcus sp., Enterococcus sp. Escherichia co/i, Pseudomonas aeruginosa E. co/i, Staphylococcus epidermidis N.D. N.D. C. albicans MRSA MRSA, Pseudomonas sp. N.D. C. albicans N.D. C. albicans N.D. N.D. N.D.

N.D., Not described.

tious complications. Hull et a1.53 suggest other measures to decrease complications for feeding gastrostomies, including (1) an experienced nutritional team to supervise wound care, (2) a predischarge training program for patients and families, (3) careful outpatient follow-up, (4) a knowledgeable medical staff available for patient telephone access, and (5) a patient identification card with emergency contact numbers and advice.53 Although not generally recognized, use of feeding gastrostomy tubes can result in both infectious and noninfectious complications. Gottlieb and Mobarhar?* cite evidence that gastrostomy tubes are initially colonized by oral organisms that have made their way into the stomach, where they may reside either transiently or permanently.58 Colonization of percutaneous gastrostomy tubes from the skin and hospital environment is also possible. 58,59The inside of this tube is a haven for microbes because of high humidity, regular provision of nutritional culture medium, a temperature of almost 37” C, and protection from immune defense mechanisms.59 In most cases gastrostomy placement should not be done for terminally ill patients or for those with irreversible coma. Stiegmann et a1.54acknowledge that some of their patients had a short life

expectancy, and the reason for percutaneous tube placement was to send them to nursing homes; these authors agree that some patients should be allowed to die without gastrostomy, but they pose the ethical question of who should decide which patients are to undergo this procedure. We concur with several authors who suggest that candidates for percutaneous gastrostomy tube placement should require enteral nutrition for at least 4 to 6 weeks and have a prognosis that justifies nutritional support. 3S~‘,57,60,61Ditesheim et al.46 consider the presence of psychosis and dementia as relative contraindications for this procedure, because such patients may dislodge the tube, which could lead to serious complications. We agree with Wilkinson and Pickleman6’ who approach this problem by discussing short-term mortality rates and poor long-term prognosis in comatose patients with both medical colleagues and patients’ families. Our retrospective review in a small urban community hospital shows that permanent percutaneous feeding gastrostomy tubes are frequently used and, in most cases, are safe. However, in a small percentage of cases, this procedure can lead to serious infectious complications, including death. The role of the ICP is central in developing guide-

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lines for the placement and care of these tubes; identifying early infections that need prompt treatment; and educating medical staff, patients’ families, and the long-term care facilities in the community about the potential for infection use of these tubes presents.

2 1. 22.

23.

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