Percutaneous endoscopic gastrostomy (PEG), used for long-term enteral nutrition is associated with postprocedural infections. Therefore, the European Society of Gastrointestinal Endoscopy (ESGE) recommends periinterventional intravenous antimicrobial prophylaxis. This study aimed to evaluate guideline adherence, determine the impact of different antibiotic strategies on infection rates and analyze their association with 90-day survival post PEG-Implantation. 

This retrospective single-center study included all patients who underwent PEG placement between January 2017 and December 2023. Patients were categorized into four groups based on their periinterventional antibiotic status: no antibiotics, ongoing antibiotic treatment, pre-interventional EGSE-compliant prophylaxis and pre-interventional non-compliant prophylaxis. Infections were defined as newly elevated CRP values >5 mg/dl and/or clinical or microbiological signs of infection within 7 days post-PEG. Group comparisons used Fisher's exact test and Mann-Whitney U tests; pairwise odds ratios (OR) with confidence intervals (CI) were calculated. Ninety-day mortality was analyzed using Kaplan-Meier estimates with log-rank tests. Effect sizes were expressed as rank-biserial correlation coefficients (r). Analyses were performed using RStudio (4.4.3).

 A total of 689 patients, median age 68 years (IQR 18.2), 39% female, were included. Indications for PEG were tumors (45.6%), cerebrovascular events (35.1%), and neurological diseases (19.3%). Pre-interventional single-shot prophylaxis was administered in 427 cases (62%), 148 patients (21.5%) were already on antibiotic treatment at the time of PEG placement, and 90 (13.1%) received no antibiotics, 24 patients (3.5%) were excluded. Cephalosporins (51.1%) and penicillin combined with β-lactamase inhibitors (29.3%) were most frequently used, resulting in an overall ESGE-adherence of 91.4%, with some leniency (i.e., considering broader coverage as ESGE-compliant). The overall postprocedural infection rate was 22.6% (n=128), the most common sources were unclear (40.6%), local infections at the insertion site (19.5%), peritonitis (10.9%), and pneumonia (10.2%). Infection rates did not differ significantly between ESGE-complaint vs. non-complaint prophylaxis (18.5% vs. 26.7%; OR 0.62, 95%CI 0.17-2.77, p=0.49). The numerically highest postprocedural infection rate was observed in patients receiving no antibiotics (28.4%; OR 1.74, 95%CI 0.93-3.20, p=0.07). Patients on systemic antibiotics at the time of PEG placement had the second highest infection rate (27%, OR=1.63, 95%CI 0.95-2.70, p=0.053 – vs. ESGE-compliant prophylaxis). Overall, 90-day survival differed statistically significantly between the subgroups (p=0.019). The highest survival was seen with ESGE-complaint prophylaxis (83.1%), followed by non-complaint prophylaxis (78.6%) and no prophylaxis (78.7%). The lowest survival occurred in patients with ongoing antibiotic therapy (73.4%), significantly worse than ESGE-complaint prophylaxis (p=0.0015). Comparative analysis of baseline and inflammatory parameters demonstrated that patients with ongoing antibiotic therapy exhibited a higher systemic inflammatory burden, with elevated CRP (3.05 vs.1.; r=0.36, p<0.001) and leukocyte levels (8.8 vs 8.16; r=0.12; p <0.01). They also presented with higher comorbidity (CCI 6 vs 5; r=0.1, p=0.025) and poorer functional status (ECOG≥3: 45.6% vs. 26%; r=0.22, p<0.001). Also, PEG indication differed significantly between antibiotic groups (p<0.001), with tumor-patients being less often on ongoing antibiotic therapy (29.1% vs. 51.1%, p<0.001), and stroke more often (50% vs. 32.9%, p<0.001).

Overall adherence to ESGE-recommended prophylaxis was high, when also accepting broader coverage. The lowest rate of infection and highest 90-day survival was observed in patients receiving ESGE-compliant prophylaxis, while some of the analyses were not statistically significant, possibly being underpowered due to high compliance rates. Patients on ongoing systemic antibiotics exhibited the lowest 90-day survival. This finding reflected both their higher comorbidity burden and elevated inflammatory activity, confirming that systemic inflammation, frailty and comorbidities substantially contribute to post-PEG mortality. Future studies could focus on finding subgroups where optimization of patients and delaying PEG placement may improve outcomes.