Use an oral antiseptic mouthwash (chlorhexidine or aqueous iodine) to reduce bacterial presence.

Decolonise the nasopharynx if diagnosed (but not yet eradicated) of methicillin-resistant Staphylococcus aureus.

If body hair is abundant at the insertion site, use an electric shaver.

Stop a proton pump inhibitor 24 hours before the procedure.

Use a single intravenous dose of periprocedural antibiotics (a first-generation cephalosporin); unless in patients already receiving antibiotics covering skin-flora.

Apply standard measures for infection prevention including aseptic preparation of the surgical field and preoperative handwashing and/or disinfection.

Use a checklist that serves as a reminder of all necessary steps prior to and after tube placement.

Alternatively, consider administering a 20 mL co-trimoxazole solution through the newly inserted PEG catheter just after placement, instead of the periprocedural intravenous dose.

Clean the stoma and peristomal skin with a sterile solution (normal saline or local disinfection) daily for the first week and consider applying a skin protecting film or cream.

Alternatively, use a glycerin hydrogel or glycogel dressing instead of classical aseptic wound care during the first week.

Apply a (split) gauze dressing (not too thick) to remove any discharge above or under the external bumper (with a free distance of 0.5–1 cm).

Protect the skin with a nonocclusive dressing.

Avoid excessive pressure between the skin and the external bumper.

Assess the stoma and peristomal skin daily for signs and symptoms of infection such as loss of skin integrity, maceration, erythema, purulent and/or malodorous exudate, fever and pain.

Reduce (after stoma healing) dressings to once or twice a week. The entry site can be cleansed using an additive-free pH 5.5 soap and water of drinking quality.

Alternatively, dressings can be omitted and the site can be left open.

Keep the gastrostomy site as dry as possible.

Secure the tube properly and minimise friction/movement.

Apply preventive actions against peristomal infection after the procedure (also see paragraph ‘Peristomal site infection’).

Check if a low-profile device is in situ, if the device comfortably fits in the tract and has minimal movement.

Avoid side torsion on the tract wall.

Evaluate regularly if the tube is not fixed too loosely or too tightly to the skin and check for a potential buried bumper syndrome.

Check balloon inflation volume at weekly intervals (if the tube is a balloon retained gastrostomy tube) and inspect the water for evidence of stomach contents indicating balloon rupture.

Observe the ostomy site closely for infection or overgranulation tissue.

Check gastric residual volume if any signs of gastrointestinal intolerance are present (eg, nausea, vomiting, abdominal distention, constipation).

Replace the tube feeding set every 24 hours.

Flush the tube using 30 mL of pure water every 4 hours during continuous tube feedings, before and after intermittent feedings and after checking gastric residuals.

Flush with ±15 mL of water after and between each medication through the tube.

Consider adapting flushing protocols in people with restricted fluid intake, for example, 10 mL every 6 hours with continuous infusions; and 5 mL before and 10 mL after administering drugs; or interrupting or starting enteral nutrition.

Pay particular attention to avoid obstruction with jejunal tubes because they tend to have smaller calibres than gastric tubes.

Never rotate a PEG with a jejunal extension (PEG-J).

Critically evaluate the medication: which drugs are really necessary, which medication has an alternative form (eg, liquid, effervescent tablet, syrup).

Crush, dissolve and administrate drugs separate from each other to prevent incompatibility.

Use sterile water in immunocompromised or critically ill patients if there are concerns about the safety of pure water.