Cost analysis of antibiotic prophylaxis for PEG

Redetermining the cutoff point of peristomal infection scoring: Methodological research

BACKGROUND

Peristomal infections are a frequently encountered problem in enteral nutrition that warrants prompt diagnosis and early antimicrobial treatment. Current practice lacks a consensus on an accepted measurement tool with acknowledged validity and reliability. The Peristomal Infection Scoring System is one such tool that shows promise, yet the optimal cutoff value remains to be determined.

METHODS

This methodological research was conducted with 54 adult participants to evaluate their peristomal areas in terms of infection by two nurse nutritionists and an expert physician in a simultaneous and independent manner, using peristomal infection scoring or the local signs and symptoms of infection. Performance was assessed by the receiver operating characteristic curve, interobserver reliability, and validity metrics.

RESULTS

According to the expert physician's opinion, the peristomal infection rate was 9.2%. The agreement between the observers using the Peristomal Infection Scoring System was κ = 1,000, P < .001. The peristomal infection scoring area under the receiver operating characteristic curve was 0.98 (P < .001), and the best cutoff value was found to be 6 points, which correlated positively with a 0.88 coefficient (P < .001) and an accuracy of 98.1% (CI, 90.11%-99.95%).

CONCLUSION

The Peristomal Infection Scoring System with a cutoff value of 6 points is a valid and reliable instrument to diagnose peristomal infections. It can be easily used by healthcare professionals in all settings as needed.

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

PURPOSE

The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation.

METHODS

This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure.

RESULTS

Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00).

CONCLUSIONS

Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees.

LEVEL OF EVIDENCE

Prospective comparative treatment study, level II.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a surgical procedure performed to maintain nutrition in the short- or long-term. During the procedure, a feeding tube that delivers either a liquid diet, or medication, via a clean or sterile delivery system, is placed surgically through the anterior abdominal wall. Those undergoing PEG tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, or underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and to the debate surrounding antibiotic prophylaxis for PEG tube placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient's serum and tissues, via a brief course of an appropriate agent, by the time of PEG tube placement in order to prevent any peristomal infections that might result from the procedure.

OBJECTIVES

To establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomy tubes.

SEARCH METHODS

In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid Medline; Ovid Medline (In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials during PEG tube placement, with no restrictions regarding language of publication, date of publication, or publication status. Both review authors independently selected studies.

DATA COLLECTION AND ANALYSIS

Both review authors independently extracted data and assessed study quality. Meta-analyses were performed where appropriate.

MAIN RESULTS

One new trial was identified and included in this update, bringing the total to 13 eligible RCTs, with a total of 1637 patients. All trials reported peristomal infection as an outcome. A pooled analysis of 12 trials resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (1271 patients pooled: OR 0.36, 95% CI 0.26 to 0.50). The newly identified trial compared IV antibiotics with antibiotics via PEG and could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

Administration of systemic prophylactic antibiotics for PEG tube placement reduces peristomal infection.

Enteral nutrition access devices

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, performing a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but, in many cases, data from randomized, controlled trials are lacking. In such situations, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the ASGE Governing Board. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to endoscopy in patients requiring enteral feeding access by using the keywords "endoscopy," "percutaneous," "gastrostomy," "jejunostomy," "nasogastric," "nasoenteric," "nasojejunal," "transnasal," "feeding tube," "enteric," and "button." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Novel approach to antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): randomised controlled trial

OBJECTIVE

To evaluate a new and simpler strategy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG).

DESIGN

Single centre, two arm, randomised, controlled, double blind clinical trial.

SETTING

Endoscopy unit in Karolinska University Hospital, Stockholm, Sweden, between 3 June 2005 and 31 October 2009.

PARTICIPANTS

234 patients with an indication for PEG who gave informed consent to participate.

INTERVENTION

A single 20 ml dose of the oral solution of sulfamethoxazole and trimethoprim (also known as co-trimoxazole or Bactrim; F Hoffmann-La Roche Ltd, Basel, Switzerland) deposited in the PEG catheter immediately after insertion. The control group received standard prophylaxis consisting of a single intravenous dose of 1.5 g cefuroxime (Zinacef; GlaxoSmithKline, London) administered before insertion of the PEG tube.

MAIN OUTCOME MEASURE

Primary outcome was the occurrence of clinically evident wound infection within 14 days after insertion of the PEG catheter. Secondary outcomes were positive bacterial culture and blood tests (highly sensitive C reactive protein and white blood cell count). All randomised patients were included in an intention to treat analysis.

RESULTS

Of the 234 patients included in this study, 116 were randomly assigned to co-trimoxazole and 118 to cefuroxime. At follow-up 7-14 days after insertion of the PEG catheter, wound infection was found in 10 (8.6%) patients in the co-trimoxazole group and 14 (11.9%) in the cefuroxime group, which corresponds to a percentage point difference of -3.3% (95% confidence interval -10.9% to 4.5%). The per protocol analysis, which comprised 100 patients in each group, gave similar results-10% and 13% infection in the co-trimoxazole and cefuroxime groups, respectively (percentage point difference -3.0%, 95% CI -11.8% to 5.8%). Both these analyses indicate non-inferiority of co-trimoxazole compared with cefuroxime because the upper bounds of the confidence intervals are lower than the pre-determined non-inferiority margin of 15%. Analyses of the secondary outcomes supported this finding.

CONCLUSION

20 ml of co-trimoxazole solution deposited in a newly inserted PEG catheter is at least as effective as cefuroxime prophylaxis given intravenously before PEG at preventing wound infections in patients undergoing PEG. Trial registration Current Controlled Trials ISRCTN18677736.

Local infection after placement of percutaneous endoscopic gastrostomy tubes: a prospective study evaluating risk factors

BACKGROUND

Due to its high efficacy and technical simplicity, percutaneous endoscopic gastrostomy (PEG) has gained wide-spread use. Local infection, occurring in approximately 2% to 39% of procedures, is the most common complication in the short term. Risk factors for local infection are largely unknown and therefore--apart from calculated antibiotic prophylaxis--preventive strategies have yet to be determined.

OBJECTIVE

To assess the potential patient- and procedure-related risk factors for peristomal infection following PEG tube placement.

METHODS

Potential patient-related (eg, age, sex, diseases, body mass index, concomitant antibiotic therapy) and procedure-related (endoscopist experience, institutional factors, findings on endoscopy) risk factors and their coincidence with local infection, defined as a positive peristomal infection three days after PEG tube placement, were evaluated at two institutions. A standardized antibiotic prophylaxis was not performed. The peristomal infection score was also evaluated in 390 patients.

RESULTS

Using a multivariate binary regression analysis, four risk factors were established as relevant for local infection after PEG: clinical institution (OR 6.69; P = 0.0001), size of PEG tubes (15 Fr versus 9 Fr; OR 2.12; P = 0.05), experience of the endoscopist (more than 100 investigations versus less than 100 investigations; OR 0.54; P = 0.05) and the existence of a malignant underlying disease (OR 2.28; P = 0.019).

CONCLUSIONS

Similar to other endoscopic interventions, local infection as a complication of PEG tube placement depends on the experience of the endoscopist. Institutional factors also play a significant role. Additional risk factors include PEG tube size and underlying diseases. These findings indicate that the local infection after PEG tube placement may be influenced by both endoscopy-associated factors and by the underlying disease status of the patient.

A systematic review of prophylactic antimicrobials in PEG placement

AIM

To establish whether prophylactic systemic antimicrobials reduce the risk of peristomal infection in placement of percutaneous endoscopic gastrostomies.

BACKGROUND

Percutaneous endoscopic gastrostomies, placed surgically through the anterior abdominal wall, maintain nutrition in the short or long term. Those undergoing percutaneous endoscopic gastrostomy placement are often vulnerable to infection. The increasing incidence of methicillin-resistant Staphylococcus aureus contributes an additional risk to the debate surrounding antibiotic prophylaxis. The aim of antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patient, during placement.

DESIGN

Systematic review.

METHODS

We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals, relevant conference proceedings and bibliographies of publications identified, and contacted manufacturers and distributors of percutaneous endoscopic gastrostomy products. Randomised controlled trials were selected evaluating the use of prophylactic antimicrobials for percutaneous endoscopic gastrostomy placement, with no restrictions for language, date or publication status. Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate.

RESULTS

Ten eligible randomised controlled trials were identified evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22-0.44). The relative reduction in risk of infection for those given antibiotics was 19% with the need to treat 5.8 patients to prevent one infection - NNT.

CONCLUSIONS

Administration of systemic prophylactic antibiotics for percutaneous endoscopic gastrostomy placement reduces peristomal infection.

RELEVANCE TO CLINICAL PRACTICE

The nurse's role in endoscopy is expanding rapidly and demands that practice is based on the best available evidence. This systematic review seeks to make a contribution to best practice in percutaneous endoscopic gastrostomy placement.

Enteral access options and management in the patient with intestinal failure

Intestinal failure refers to a condition in which inadequate digestion and/or absorption of nutrients leads to malnutrition and/or dehydration. Enteral access is occasionally used in patients with intestinal failure either for the purpose of providing nutrition or decompressing the gut. As a consequence, it is important that clinicians caring for these highly complex patients be knowledgeable in enteral access options and experienced in the subsequent care of these tubes. In this review, enteral access options and the potential complications associated with their use will be reviewed. Importantly, this information is relevant to both the pediatric and adult patient with intestinal failure.

Minimizing endoscopic complications in enteral access

Percutaneous enteral access techniques are important tools in the armamentarium of the skilled endoscopist. Endoscopic and post-procedural complications of enteral access are not uncommon, and the increasing population of patients requiring long-term feeding tubes places even more emphasis on minimizing them. Most enteral feeding tube complications are minor, but several have the potential to cause significant morbidity and even mortality if not recognized and managed correctly. When complications do arise, early recognition and aggressive management are essential to optimize outcomes. Expertise with the proper patient selection, choice of feeding tube and insertion techniques are critical to minimizing endoscopic complications of percutaneous enteral feeding tubes.

Covering the percutaneous endoscopic gastrostomy (PEG) tube prevents peristomal infection

BACKGROUND

Because oropharyngeal bacteria can be brought through the abdominal wall during percutaneous endoscopic gastrostomy (PEG), peristomal infection is one of the most frequent complications in patients who undergo the procedure. This study aimed to determine whether covering the PEG tube with a sheath that could be detached in the stomach could help prevent peristomal infection.

METHODS

In three community hospitals in Japan, data from 449 patients with swallowing dysfunction were prospectively collected between March 2000 and February 2002 for non-covered PEG (n=206) and between March 2002 and February 2004 for covered PEG (n=243).

RESULTS

After adjusting for hospital, age, gender, and underlying diseases, covering the PEG significantly reduced peristomal purulent infection compared with non-covered PEG (odds ratio: 0.05; 95% confidence interval: 0.02-0.13). Body temperature, white blood cell count, and C-reactive protein at day 3 after PEG placement, as well as duration of antibiotics usage, were significantly lower or shorter in patients treated with covered PEG than non-covered PEG. In spite of the same frequencies in the two groups of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa in oropharyngeal cultures before PEG placement, these organisms were detected significantly less frequently in peristomal lesions of patients who underwent covered PEG. Moreover, 28 patients treated with covered PEG received no antibiotic therapy, and 27 of them had no signs of peristomal infection.

CONCLUSIONS

These results suggest that covering the PEG tube, with or without providing antibiotic therapy, may prevent peristomal infection in spite of the presence of oropharyngeal bacterial flora after percutaneous endoscopic gastrostomy.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement.

OBJECTIVES

The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status.

DATA COLLECTION AND ANALYSIS

Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44).

AUTHORS' CONCLUSIONS

Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.

Decompressive percutaneous gastrostomy tube use in gynecologic malignancies

Percutaneous gastrostomy tube placement is a technically feasible and safe procedure for palliation in patients with small bowel obstruction (SBO) caused by advanced gynecologic malignancies. It is used commonly in patients who are poor surgical candidates, those who elect to not undergo surgery, and in patients with a limited lifespan because of end-stage cancer. Percutaneous gastrostomy tube placement is even technically possible in patients with tumor encasing the stomach, diffuse carcinomatosis, and ascites. Percutaneous endoscopic gastrostomy (PEG) tubes provide symptomatic relief of nausea and vomiting in most patients with advanced gynecologic cancer and SBO. PEG tube placement allows most patients to have end- of-life care at home or in an inpatient hospice. It is a cost effective procedure and is associated with low morbidity and mortality. Placement of PEG tubes should be highly considered in patients who present with recurrent bowel obstruction and who have undergone a prior operation for SBO in the setting of advanced gynecologic malignancy.

Gastrostomy Tubes

The first successful gastrostomy was performed 130 years ago. Although it is difficult to ascertain the exact number of gastrostomy or jejunostomy tubes placed annually in the United States, it is estimated approximately 230,000 gastrostomy procedures were performed in U.S. hospitals in 2001. Of these, 11,000 were performed in children. Despite the many years gastrostomy tubes have been in use, they are not free from complications. The purpose of this article is to review the authors' experience with pediatric patients who have undergone radiographic placement of gastrostomy or jejunostomy tubes.

Percutaneous gastrostomy in patients with a ventriculoperitoneal shunt: case series and review

BACKGROUND

There are few data on the safety of PEG in patients with a ventriculoperitoneal shunt.

METHODS

Medical records for patients seen in 3 tertiary care, university-affiliated hospitals between January 1, 1991, and January 1, 1999, were reviewed.

OBSERVATIONS

Six patients underwent PEG after ventriculoperitoneal shunt placement during the study period. There was no immediate complication. One patient died of pneumonia 2 months after PEG insertion. There was no instance of shunt malfunction, intra-abdominal complication, or wound infection in the study group. There was no long-term complication, with either the ventriculoperitoneal shunt or the PEG.

CONCLUSIONS

Although the number of cases was small, PEG placement with prophylactic administration of antibiotics appears to be safe in patients with a pre-existing ventriculoperitoneal shunt.

Gastrostomy insertion: comparing the options--PEG, RIG or PIG?

AIM

To compare percutaneous endoscopic gastrostomy (PEG) with radiologically inserted gastrostomy (RIG) and assess a hybrid gastrostomy technique (per-oral image-guided gastrostomy, PIG).

MATERIALS AND METHODS

Fifty PEGs and 50 RIGs performed in three centres were prospectively compared and the endoscopic findings of 200 PEGs reviewed. A fluoroscopy-guided technique was modified to place 20 F over-the-wire PEG-tubes in 60 consecutive patients.

RESULTS

Technical success was 98%, 100% and 100% for PEG, RIG and PIG, respectively. Antibiotic prophylaxis significantly reduced stoma infection for orally placed tubes (p=0.02). Ten out of 50 (20%) small-bore RIG tubes blocked. Replacement tubes were required in six out of 50 PEGs (12%), 10 out of 50 RIGs (20%), but no PIGs (p<0.001). No procedure-related complications occurred. The function of radiologically placed tubes was significantly improved with the larger PIG (p<0.001), with similar wound infection rates. PIG was successful in 24 patients where endoscopic insertion could not be performed. Significant endoscopic abnormalities were found in 42 out of 200 PEG patients (21%), all related to peptic disease. Insignificant pathology was found in 8.5%.

CONCLUSION

PIG combines advantages of both traditional methods with a higher success and lower re-intervention rate. Endoscopy is unlikely to detect clinically relevant pathology other than peptic disease. PIG is a very effective gastrostomy method; it has better long-term results than RIG and is successful where conventional PEG has failed.

Enteral nutrition delivery technique

PURPOSE OF REVIEW

Ingestion and absorption of a nutritionally adequate diet is necessary to maintain normal body composition and organ function. Patients with all kinds of diseases are at increased risk of developing nutritional abnormalities from anorexia, dietary restriction, malabsorption, increased intestinal losses or altered nutrient requirements. Therefore, it is important for doctors to understand the general principles of clinical nutrition for optimal management of patients with various disorders. The purpose of this review is to highlight an important aspect of nutrition: methods for enteral nutrient delivery. Enteral feeding is the preferred method to provide nutritional support in patients who cannot or will not eat but who have a functional gastrointestinal tract. The placement of a small-diameter nasogastric or nasoduodenal tube is the simplest technique for feeding patients who are unlikely to require tube feeding for more than 6 weeks. Gastrostomy, gastrojejunostomy and jejunostomy tubes placed by using endoscopic, radiologic, or surgical techniques should be considered in patients who require long-term feeding. With newer endoscopic feeding techniques replacing more conventional surgical techniques, this review proposes to discuss the newer developments in techniques of enteral feeding.

RECENT FINDINGS

This review will briefly discuss the principles governing nasoenteral feeding and will describe in detail the endoscopic assisted methods for placing enteral feeding tubes. These include percutaneous endoscopic gastrostomy, jejunal extension through a percutaneous endoscopic gastrostomy or direct endoscopic jejunostomy. It will also discuss the procedural complications and long term results of these methods of enteral feeding. Lastly the latest innovation in enteral feed - the one step button - is also discussed.

SUMMARY

Percutaneous endoscopic gastrostomy placement is an appropriate method for providing nutrition in ill patients if no contraindication to enteral feeding exists. In certain situations, percutaneous endoscopic gastrostomy placement may even be used to make the life of a terminally ill patient comfortable.

Antimicrobial prophylaxis in the surgical patient

The primary prophylactic measure against postoperative infection is antiseptic technique in patient preparation, during surgery, and in postoperative patient care. Antimicrobial prophylaxis against postoperative infection is not indicated for procedures with a low infection rate because the expected benefit of antimicrobial treatment is less than the risk of an adverse medication reaction. Antimicrobial prophylaxis has been demonstrated to be of greater benefit than risk in some procedures with higher infection rates; however, because the problem is complex and the data are limited, extra-polating these findings to the practitioner's setting and the individual patient remains a challenge (Table 1). Although antimicrobial prophylaxis for bacterial endocarditis is not effective for most patients, the seriousness of the potential infection has driven the creation of guidelines recommending prophylaxis for at-risk patients undergoing at-risk procedures. Applying these guidelines appropriately could help to reduce unwarranted use of antimicrobials. In the prophylactic use of antimicrobials, as in many medical interventions, the difficulty is balancing the risks of the intervention with the potential benefits. Although we do not have either the randomized, controlled trials or the detailed, patient-specific information to estimate this balance precisely, there are general guidelines to help the clinician choose treatment for most patients.

PEG site infections: a novel use for Actisorb Silver 220

Any breach in the integrity of the skin, such as occurs in wounds and incisions, and intravascular catheters, can act as a portal for the ingress of microorganisms and thereby predispose the patient to infection. The infection, if unchecked, can put the patient at risk of bacteraemia. We have reviewed the care of percutaneous enterostomal gastrostomy (PEG) sites in our trust hospital and in the local community and have implemented practice guidelines to reduce infection risks. These include protocols for skin care around PEG sites, and the use of an antibacterial dressing - Actisorb Silver 220 - to manage local colonization. The preliminary results of this exercise indicate that patient comfort can be improved, hypergranulation reduced, and methicillin-resistant Staphylococcus aureus colonization and infection eradicated.

Role of endoscopy in enteral feeding

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. A previous guideline related to this topic (ASGE Publication No. 1017, Gastrointest Endosc 1998;48:699-701). Since that time, new information has become available that requires an update of this statement and its recommendations. In preparing this update, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from the recommendations of expert consultants. When inadequate data existed from well-designed prospective trials, emphasis was given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance from these recommendations.

Complications of upper GI endoscopy

This is one of a series of statements discussing the utilization of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

A survey on percutaneous endoscopically placed gastrostomy in the Northwest: influence of work setting

OBJECTIVE

A survey was undertaken to determine the influence of practice setting on the way Pacific Northwest gastroenterologists perform and manage percutaneous endoscopically placed gastrostomy (PEG).

METHODS

A 12-question survey was distributed to 196 members of the Pacific Northwest Gastroenterology Society (PNWGS) regarding their specifics of placing and managing PEG. The responses were compared according to work setting, i.e., private practice, armed services, staff model HMO's, and university affiliated hospitals. The data were analyzed using the chi2 test.

RESULTS

Sixty-nine of 126 practicing gastroenterologists responded; 75% were in private practice (PP) and 25% in the combined other work settings (non-PP). The mean number of PEG placed by all groups was 23. Seventy-three percent of PP performed PEG without a second physician. Antibiotics were used prophylactically in both PP and non-PP by 96%. There was no difference between groups in use of standardized forms or in time before instituting feedings. The non-PP groups used preprocedure labs (p = 0.037) and loosening skin surface bumpers (p = 0.035) more frequently. The uniform impression was that PEG was associated with the same or fewer complications currently than in the past.

CONCLUSIONS

In the PP setting, gastroenterologists tend to place PEGs without a second physician and use standardized forms and bumper loosening less frequently than non-PP gastroenterologists. These variations reflect that teaching institutions as well as staff model HMOs make access to an assistant easier. Respondents expressed confusions on billing for PEG. They perceived the procedure to be as safe or safer than in the past. The PEG has evolved into a frequently performed procedure whose practice variations are outgrowths of one's work environment as well as one's training.