9 10 11 12 A single intravenous dose of the cephalosporin

Meta analyses of randomised trials have established that wound infection rates decrease substantially when intravenous antibiotic prophylaxis is given before the PEG procedure.9 10 11 12 A single intravenous dose of the cephalosporin cefuroxime (Zinacef; GlaxoSmithKline, London), given one hour before the PEG procedure, is well established as the gold standard method of antibiotic prophylaxis and is recommended by the British Society of Gastroenterology (evidence grade Ia and recommendation grade A)13 because of its good effect on the bacteria commonly found in the upper gastrointestinal tract.14 15 Disadvantages of this strategy include the high cost, the need to give the medication intravenously, and the need to give it before insertion of the PEG catheter, even though in about 10% of patients insertion of the catheter proves to be impossible.16We hypothesised that there is a less expensive, technically easier, and at least as effective way of infection prophylaxis than using cefuroxime; that is pandora jewellery, depositing a single dose of a combination of a sulphonamide and trimethoprim (also known as co trimoxazole or Bactrim; F Hoffmann La Roche Ltd, Basel, Switzerland), as an oral solution, directly in the newly inserted PEG catheter. To test this hypothesis we conducted a large randomised clinical trial.MethodsDesign and interventionWe undertook a double blind, randomised clinical trial to test whether a single dose of 20 ml co trimoxazole (800 mg sulfamethoxazole and 160 mg trimethoprim) deposited in the PEG catheter immediately after insertion was at least as good (non inferiority assumption) for the prevention of acute wound infections as the standard antibiotic prophylaxis of a single intravenous dose of 1.5 g of cefuroxime administered one hour before insertion of the PEG catheter. We chose co trimoxazole rather than an oral cephalosporin as the test drug because of the following advantages: more rapid absorption in the upper gastrointestinal tract; longer half life; doesn't need to be mixed with food intake (which is difficult immediately after PEG); lower risk of infection with Clostridium difficile17 18; and lower price.PatientsAll patients at the Karolinska University Hospital, Stockholm, Sweden, who were referred to the endoscopy unit for PEG during the period 3 June 2005 to 31 October 2009 were considered for inclusion.

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