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Thrombophlebitis, Septic

Last = Updated:=20 April 10, 2002
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Synonyms and related = keywords:=20 septic phlebitis, septic = thrombophlebitis

  AUTHOR INFORMATION=20 Section 1 of = 10   =20
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography
Author: Craig = Feied, MD,=20 FACEP, FAAEM, Director of Informatics, = Department of=20 Emergency Medicine, Washington Hospital Center; Clinical = Associate=20 Professor, Department of Emergency Medicine, George = Washington Univ;=20 Director, National Center = for=20 Emergency Medicine Informatics

Coauthor(s): Jonathan A=20 Handler, MD, Director of Informatics, Assistant = Professor, Department of Emergency Medicine, Northwestern = Memorial=20 Hospital

Craig Feied, MD, FACEP, FAAEM, is a member of the = following=20 medical societies: American = Academy=20 of Emergency Medicine, American=20 College of Emergency Physicians, American College of=20 Phlebology, American College=20 of Physicians, American=20 Medical Association, American=20 Medical Informatics Association, Medical Society of the = District of=20 Columbia, Society for = Academic=20 Emergency Medicine, and Undersea=20 and Hyperbaric Medical Society

Editor(s): Richard S Krause, MD, Program=20 Director, Clinical Assistant Professor, Department of = Emergency=20 Medicine, State University of New York at Buffalo; = Francisco=20 Talavera, PharmD, PhD, Senior Pharmacy Editor, = Pharmacy,=20 eMedicine; Eddy Lang, MDCM, CCFP (EM), = CSPQ,=20 Assistant Professor, Department of Family Medicine, McGill=20 University; Consulting Staff, Department of Emergency = Medicine, The=20 Sir Mortimer B Davis-Jewish General Hospital; John = Halamka,=20 MD, Chief Information Officer, CareGroup Healthcare = System,=20 Assistant Professor of Medicine, Department of Emergency = Medicine,=20 Beth Israel Deaconess Medical Center; Assistant Professor of = Medicine, Harvard Medical School; and Charles V = Pollack, Jr,=20 MD, MA, Associate Professor, Department of = Emergency=20 Medicine, University of Pennsylvania College of Medicine; = Chairman,=20 Department of Emergency Medicine, Pennsylvania Hospital=20

Background: = The=20 approach to septic phlebitis depends on the location and type of = the=20 involved veins, the underlying cause of the septic phlebitis, and = the=20 organisms involved. Septic phlebitis of the deep veins is a=20 life-threatening emergency that may fail to respond to even the = most=20 aggressive therapy.=20

Peripheral septic thrombophlebitis is a common problem that can = develop=20 spontaneously but most often is associated with breaks in the = skin.=20 Peripheral septic phlebitis commonly is caused by intravenous (IV) = catheters, venipuncture for phlebotomy, or licit or illicit IV = injections.=20 Peripheral septic phlebitis often produces a septicemia that can = seed=20 secondary sites of infection.=20

Catheter-related septic phlebitis is one of the most common = causes of=20 fever after the third postoperative day. Catheter-associated = phlebitis may=20 develop at any site but is most frequent after cannulation of = lower limb=20 veins and veins at the groin.=20

Septic phlebitis of a superficial vein without frank purulence = is=20 referred to as "simple phlebitis." Simple phlebitis can be benign, = but it=20 also can progress to cause serious complications and even death.=20

Suppurative superficial thrombophlebitis, in which actual = purulent=20 material can be expressed from a vein, is a much more serious = condition=20 that often is associated with generalized septicemia and has a = high rate=20 of mortality even when treated aggressively. Patients with = suppurative=20 phlebitis can appear quite ill, with high fevers and disseminated = signs of=20 infection.=20

Septic pelvic thrombophlebitis and septic ovarian vein = thrombophlebitis=20 are seen principally as complications of puerperal infections and = of=20 septic abortions. Occasionally, septic pelvic phlebitis may be a=20 complication of pelvic inflammatory disease or severe urinary = tract=20 infections. In diverticulitis, infection may spread to cause = septic=20 phlebitis of the portal vein (pylephlebitis).=20

Lemierre syndrome is an anaerobic suppurative thrombophlebitis=20 involving the internal jugular vein, most often as a complication = of=20 pharyngeal, dental, or mastoidal infection. Lemierre syndrome is = much more=20 common than generally appreciated, and often it is complicated by = septic=20 emboli. Septic emboli can lodge in the lungs (septic pulmonary = emboli) or=20 can pass into the systemic arterial circulation and produce = distant=20 metastatic infections. Common secondary infections include septic=20 arthritis, paravertebral abscesses, skin infections, thigh = abscesses,=20 periorbital cellulitis, meningitis, and osteomyelitis.=20

Septic cavernous sinus and lateral sinus thrombophlebitis are = extremely=20 serious complications that may follow infections of the medial = third of=20 the face (cavernous sinus) or mastoiditis (lateral sinus). Even = with=20 appropriate therapy, septic intracranial thrombophlebitis is fatal = in more=20 that one third of cases.

Pathophysiology: Septic phlebitis can develop=20 spontaneously or as a result of any break in the skin that = introduces=20 virulent organisms. Septic phlebitis most commonly occurs as an = infection=20 associated with a long-term IV cannula being used for = administration of=20 fluids or medications.=20

Prolonged catheterization, use of semipermeable transparent = dressings,=20 and a jugular insertion site all are independent risk factors for=20 developing septic phlebitis. Septic phlebitis often complicates = other=20 illnesses that depress the immune response, including = malnutrition,=20 diabetes, liver disease, and malignancy, and occurs in patients = taking=20 immunosuppressant agents.=20

Catheter-associated septic thrombophlebitis often progresses to = involve=20 the deep veins; nearly one fourth of long-term central venous = catheters=20 result in septic phlebitis within the deep system.=20

Deep or superficial septic phlebitis also can occur by direct = invasion=20 from adjacent nonvascular infections. Endometritis or urinary = tract=20 infections, for example, may spread to cause septic pelvic=20 thrombophlebitis or septic ovarian vein thrombophlebitis. = Pylephlebitis=20 (septic thrombophlebitis of the portal vein) usually occurs as a = secondary=20 complication of diverticulitis or another infection in the region = drained=20 by the portal venous system.=20

Systemic effects can be due to bacteremia per se or may be = related to=20 bacterial endotoxin production. Streptococcal toxic shock syndrome = has=20 been reported in association with pediatric peripheral septic=20 thrombophlebitis.=20

No matter what the original etiology or site of infection, = septic=20 thrombophlebitis often produces a secondary endocarditis, = arteritis, or=20 pneumonia due to septic pulmonary thromboemboli. Embolic = pneumonias have a=20 high incidence of abscess formation and cavitation. Peripheral = septic=20 metastases are seen in patients who develop left-sided = endocarditis and in=20 those with right-sided endocarditis who also have a patent foramen = ovale.=20

The etiologic agent of septic or suppurative phlebitis usually = can be=20 cultured both from blood and from any metastatic sites of = infection.=20 Septic phlebitis can be caused by gram-positive or gram-negative = organisms=20 or by candidal or mycobacterial species. Staphylococcus=20 epidermidis, group A streptococcus, and the = Klebsiella and=20 Enterobacter species are very common causes of phlebitis, = but the=20 worst complications are seen in patients with phlebitis due to=20 Candida species, Pseudomonas aeruginosa, or=20 Staphylococcus aureus.=20

The organism responsible often can be predicted from the site = of=20 infection. Peripheral bacterial phlebitis virtually always is = caused by=20 aerobic organisms, while septic pelvic thrombophlebitis and septic = internal jugular phlebitis (Lemierre syndrome) are usually related = to=20 anaerobic pathogens. The organism that most often causes Lemierre = syndrome=20 is Fusobacterium necrophorum, an endotoxin-producing=20 gram-negative obligate anaerobe that can be found in the upper=20 respiratory, gastrointestinal, and genitourinary tracts. Other = organisms=20 that may cause Lemierre syndrome include Bacteroides = melaninogenicus,=20 Eikenella corrodens, and non-group A streptococci. The = bacteremia of=20 pylephlebitis is often polymicrobial, reflecting the underlying=20 diverticular source, but the most common blood isolate is = Bacteroides=20 fragilis. Septic cavernous sinus thrombophlebitis most often = is=20 caused by S aureus.

Frequency:

  • In the US: The annual incidence is unknown, = but=20 septic phlebitis due to IV catheters is one of the most common = causes of=20 fever after the third postoperative day, occurring in at least = 12% of=20 patients who have undergone surgery. Patients in the intensive = care unit=20 (ICU) are at particularly high risk: 24% of ICU patients with = central=20 venous catheters and 9% of those with peripheral catheters = develop fever=20 and bacteremia and have positive results on culture of the = venous=20 catheter tip.

Mortality/Morbidity: Major complications occur = in one=20 third of all episodes of peripheral septic phlebitis caused by=20 percutaneously inserted catheters.=20

  • Complications include septic shock, sustained or refractory = sepsis,=20 suppurative thrombophlebitis, metastatic infection, = endocarditis, and=20 arteritis. Patients may die because of sepsis, and hospital stay = is=20 prolonged in the majority of cases.
  • In critically ill patients, IV lines are responsible for = about one=20 quarter of the cases of nosocomial bloodstream infection, which = has a=20 mortality rate of 25% and costs $29,000 per survivor.
  • Lemierre syndrome and intracranial septic thromboses are of = special=20 concern because the mortality rate is high even when appropriate = treatment is initiated early. Of patients with Lemierre = phlebitis, 20%=20 eventually die despite prolonged IV antibiotic therapy. The = mortality=20 rate is even higher for patients with septic cavernous sinus or = lateral=20 sinus phlebitis.

Age:

  • Vulnerability to vascular infection is increased in neonates = because=20 of their undeveloped host defenses.
  • Vulnerability is increased in elderly patients because of=20 concomitant illnesses and a nonspecific age-related decline in=20 immunopotency.
  INTRODUCTION = Section 2 of = 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

History:

Physical:

Causes: Nearly anything that disrupts the = normal skin=20 barrier to infection can produce soft-tissue infections that may = result in=20 septic phlebitis.

  CLINICAL = Section 3 of = 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

Abortion, = Septic=20
Appendicitis,=20 Acute
Bites,=20 Animal
Bites,=20 Human
Bites,=20 Insects
Candidiasis =
Catscratch = Disease=20
Cavernous=20 Sinus Thrombosis
Cellulitis =
Cholangitis =
Cholecystitis = and=20 Biliary Colic
Deep Venous = Thrombosis=20 and Thrombophlebitis
Endocarditis =
Erysipelas =
Mastoiditis =
Necrotizing = Fasciitis=20
Otitis=20 Externa
Ovarian = Torsion=20
Pelvic=20 Inflammatory Disease
Peritonsillar = Abscess=20
Pharyngitis=20
Pregnancy,=20 Postpartum Infections
Prostatitis =
Shock, Septic =
Sinusitis=20
Thrombophlebitis,=20 Septic
Thrombophlebitis,=20 Superficial
Toxic Shock = Syndrome=20
Urinary=20 Tract Infection, Female


Other Problems to be Considered:

Lymphangitis

  DIFFERENTIALS = Section 4 of = 10    3D"Click
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography
Quick Find
Author=20 Information
Introduction
Cli= nical
Differentials
Worku= p
Tr= eatment
M= edication
Fo= llow-up
Miscellaneous
Bibliography

Click=20 for related images.

Related Articles
Abortion,=20 Septic

Appendicitis,=20 Acute

Bites,=20 Animal

Bites, Human=20

Bites,=20 Insects

Candidiasis=20

Catscratch=20 Disease

Cavernous=20 Sinus Thrombosis

Cellulitis=20

Cholangitis=20

Cholecystitis=20 and Biliary Colic

Deep Venous=20 Thrombosis and Thrombophlebitis

Endocarditis=20

Erysipelas=20

Mastoiditis=20

Necrotizing=20 Fasciitis

Otitis=20 Externa

Ovarian=20 Torsion

Pelvic=20 Inflammatory Disease

Peritonsillar=20 Abscess

Pharyngitis=20

Pregnancy,=20 Postpartum Infections

Prostatitis=20

Shock,Septic=20

Sinusitis=20

Thrombophlebitis,=20 Septic

Thrombophlebitis,=20 Superficial

Toxic Shock=20 Syndrome

Urinary=20 Tract Infection, Female


Continuing Education =
CME available for this topic. = Click here=20 to take this=20 = CME.

Patient Education
Click here for patient education.=20


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Lab Studies:

  • When catheter-related sepsis is suspected, blood cultures = should be=20 drawn through the line.
    • If imaging studies show thrombus or a fibrin sheath = attached to=20 the catheter, fibrinolysis should be performed prior to = catheter=20 removal in order to avoid embolization of large clumps of = infected=20 material. Once the risk of septic embolization is eliminated, = the=20 catheter should be removed in a sterile procedure and the tip = should=20 be cut off and sent for culture.
    • When suppurative phlebitis is present, the purulent = material that=20 is expressed from the vessel should be sent for Gram stain and = cultures to identify the causative organism.
  • Fever, signs of sepsis, and persistent candidemia are = characteristic=20 of peripheral septic thrombophlebitis caused by Candida = species. Candidal thrombophlebitis of the great vessels is = uncommon, but=20 it should be suspected when candidemia persists after removal of = a=20 central venous catheter and endocarditis is not believed to be=20 present.
  • White blood cell (WBC) counts are of little value in = patients with=20 septic phlebitis, because WBC counts often do not reflect the=20 seriousness of disease and because the WBC may be elevated = markedly in=20 patients with thrombophlebitis even in the absence of = infection.

Imaging Studies:

  • Imaging studies are useful to rule out thrombosis of deep = system=20 vessels, but they cannot distinguish between septic phlebitis = and=20 nonseptic thrombophlebitis.
  • The injection of contrast material into a central catheter = often=20 permits visualization of catheter-associated thrombus or of an = extensive=20 fibrin sheath that extends, cloudlike, away from the catheter. = When=20 present, a fibrin sheath is an ideal medium for = infection.
  • Contrast-enhanced CT or magnetic resonance imaging (MRI) is=20 essential when pursuing the possible diagnosis of internal = jugular vein=20 thrombophlebitis. Both CT scan and MRI can identify the extent = of=20 thrombus, the local anatomy of the affected tissues, and any = pockets of=20 purulent material that may require drainage. Other modalities = that can=20 help to make the diagnosis of Lemierre syndrome include gallium=20 scanning, retrograde venography, and duplex = ultrasonography.
  WORKUP = Section 5 of = 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

Prehospital Care: =

  • Septic phlebitis does not require any prehospital=20 intervention.

Emergency Department Care:

  • Uncomplicated superficial septic phlebitis due to a = peripheral IV=20 catheter often responds to systemic antibiotics and removal of = the=20 cannula.
    • Peripheral IV catheters should be removed at the first = sign of=20 erythema, induration, or edema.
    • The temptation to try to preserve a peripheral IV catheter = must be=20 resisted, because the morbidity and mortality rates associated = with=20 septic phlebitis are substantial and increase dramatically = over time=20 if the catheter is left in place.
  • Once phlebitis has become suppurative, simply removing the = cannula=20 is no longer sufficient. Suppurative superficial veins must be = removed=20 surgically as soon as possible.
    • Immediate excision of the involved purulent vein = dramatically=20 reduces the likelihood of spread into the deep system and of = septic=20 metastasis.
    • In many cases, the best method of removal is to perform=20 percutaneous phlebectomy using Ramelet or Mueller hooks (or = other=20 similar phlebectomy hooks) to extract the vein through a = series of=20 needle punctures or tiny stab incisions. If necessary, = suppurative=20 veins may be removed by cutdown, but the results are less = cosmetically=20 pleasing.
    • Some authors believe that a fully open approach to = phlebectomy is=20 always best because it allows the wounds to be packed open to = prevent=20 re-accumulation of pus in the subcutaneous = tissues.
    • Some authors believe that the presence of bacteremia in a = patient=20 with superficial septic phlebitis is an indication for = immediate=20 phlebectomy even in the absence of any demonstrable purulent=20 material.
  • In contrast to peripheral catheters, infected central venous = catheters should not be removed precipitously. Infected central=20 catheters often have an extensive infected free-floating fibrin = sheath,=20 and a large mass of septic thrombus may be attached to the = catheter. If=20 the catheter is withdrawn precipitously, this septic material = may=20 embolize to cause septic pulmonary emboli or septic distant=20 metastases.
    • Before an infected central catheter is removed, contrast=20 venography should be performed through the catheter to = identify any=20 fibrin sheath or thrombus. If thrombus or a sheath is present, = removal=20 should be delayed until antibiotic levels are therapeutic and = until=20 the infected thrombus or sheath can be dissolved by local=20 fibrinolysis.=20

    • Fibrinolysis in this setting is very easy and effective = because=20 the catheter tip usually is positioned perfectly to permit = delivery of=20 lytic agents directly into the fibrin sheath and thrombus. In = most=20 cases complete dissolution of the local thrombus is possible = using low=20 doses of lytic agents without producing a systemic lytic = state.=20

    • Dissolving a large mass of septic thrombus rather than = letting it=20 embolize as a whole is worth the effort. This transcatheter = procedure=20 is performed routinely by interventional radiologists, but it = may be=20 carried out easily in the ED if assistance from interventional = radiology is not immediately available.

Consultations:

  • Well-localized superficial phlebitis, even if suppurative, = does not=20 require any consultation provided the emergency physician is = capable of=20 performing the indicated superficial phlebectomy. Patients with=20 widespread suppurative phlebitis or suppurative phlebitis = threatening=20 the deep venous system, however, benefit from consultation with = a=20 vascular surgeon.
  • Infected central lines with an extensive fibrin sheath or = with=20 associated thrombus benefit from fibrinolysis and antibiotics = prior to=20 removal of the catheter. If the emergency physician cannot carry = out=20 this fibrinolysis, an interventional radiologist should be = consulted=20 prior to removing the catheter.
  • The mortality and morbidity rates of septic phlebitis are so = high=20 that antibiotic choice and dosing always should be guided by = current=20 recommendations from an expert in infectious = diseases.

  TREATMENT = Section 6 of = 10   3D"Click <= IMG=20 height=3D10 alt=3D"Click here to go to the next section in = this topic"=20 src=3D"http://www.emedicine.com/images/next3.gif" width=3D31 = align=3Dmiddle border=3D0>
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

To be effective, treatment of = progressive=20 septic phlebitis (at any location) must include both antibiotics = and=20 heparin.=20

Whenever possible, the choice of initial antibiotics should be = based=20 upon the Gram stain and the results of bacterial culture. When = Gram stain=20 is not possible, empiric therapy must take into consideration the = location=20 of the septic thrombus, the underlying etiology, and the condition = of the=20 host. No matter what the organism, extended high-dose = antimicrobial=20 therapy is recommended because of the high risk of endocarditis or = of=20 septic emboli.=20

Heparin is essential because infected thrombus provides a = dangerous=20 nidus for infection that is refractory to treatment with = antibiotics.=20 Heparin halts the progression of septic thrombophlebitis and = eliminates an=20 ongoing source of septic emboli.=20

Because heparin alone cannot dissolve existing infected clot, = septic=20 thrombophlebitis of the deep veins is an indication for = local-regional=20 treatment with fibrinolytic agents along with antibiotics and = heparin.=20 Fibrinolysis also is indicated when septic phlebitis involves a = dialysis=20 graft, when septic phlebitis is resistant to antibiotics and = heparin, and=20 when catheter-associated thrombus and fibrin sheaths cause = sequestration=20 of infection and make it resistant to treatment. Because removal = of an=20 infected indwelling catheter often causes septic emboli, = fibrinolytic=20 agents also are used before removing an infected central catheter = that has=20 an extensive fibrin sheath and thrombus associated with it.

Drug Category: Fibrinolytics = (thrombolytics)=20 -- The goal of fibrinolytic therapy is to dissolve an = infected=20 fibrin sheath or an infected thrombus that can serve as a nidus = for=20 resistant infection and as a source of septic emboli.=20

Catheter-directed local infusions of fibrinolytic agents are = safer than=20 systemic fibrinolytic regimens because they use a low dose of the = drug and=20 usually do not produce a systemic lytic state. Several = fibrinolytic agents=20 currently are available for local-regional lysis of infected = thrombus.=20

Reteplase is a second-generation recombinant tissue-type = plasminogen=20 activator that seems to work more quickly and to have a lower = bleeding=20 risk than the first-generation agent (alteplase).=20

Alteplase is the first-generation recombinant tissue-type = plasminogen=20 activator. It is the fibrinolytic agent most familiar to EDs and = the one=20 most often used for the treatment of coronary artery thrombosis, = pulmonary=20 embolism, and acute stroke.=20

Urokinase is the fibrinolytic agent most familiar to = interventional=20 radiologists and the one that has been used most often for septic=20 phlebitis. At the time of this writing, urokinase is not available = from=20 the manufacturer. The future availability of urokinase is not = known. In=20 the meantime, the US Food and Drug Administration (FDA) has = encouraged the=20 off-label use of reteplase and alteplase for local-regional lysis = of=20 venous and arterial thrombus at any location.=20

Streptokinase is a less-expensive alternative that = unfortunately is=20 highly antigenic and produces a high incidence of untoward = reactions. This=20 drawback limits the usefulness of streptokinase in the clinical = setting.

  MEDICATION = Section 7 of = 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography
Drug Name
 Reteplase (Retavase) --=20 Second-generation recombinant tissue-type plasminogen = activator. As=20 fibrinolytic agent, seems to work faster than its = forerunner,=20 alteplase, and also may be more effective in patients with = larger=20 clot burden. Also has been reported to be more effective = than other=20 agents in lysis of older clot. In patients being treated for = peripheral vascular disease, has been reported to cause = fewer=20 bleeding complications than alteplase.
Contrast = venography=20 used to guide duration and intensity of therapy.
For = local=20 lysis of arterial thrombosis (with or without associated = infection),=20 suggested dose is lower (0.5 U/h infusion).
Adult Dose For venous thrombus: 1 = U/h=20 local/regional infusion for 18-36 h
For infected = catheter=20 thrombus or fibrin sleeve: 1 U/h for 3 h
For = thrombosed=20 dialysis grafts: 5-10 U/h bolus by pulse-spray delivery
Pediatric Dose Not established
Contraindications Documented = hypersensitivity;=20 uncontrolled hypertension; recent intracranial surgery;=20 arteriovenous malformation or aneurysm; bleeding diathesis
Interactions May increase effects of = warfarin,=20 heparin, and aspirin
Pregnancy C - Safety for use during = pregnancy=20 has not been established.=20
Precautions Caution in cardiovascular = arrhythmias, hypotension, and perfusion arrhythmias; when = used as=20 infusion for local or regional fibrinolysis, some monitor = fibrinogen=20 levels at 6 h intervals; if systemic fibrinogen levels drop = below=20 100 U, infusion rate reduced by half
Drug Name
 Alteplase (Activase) -- = First=20 recombinant tissue plasminogen activator to be released for = clinical=20 use, and agent with which EDs are most = familiar.
Although=20 best known as fibrinolytic agent used for coronary artery = occlusion=20 and for PE, also widely used for catheter-directed lysis of = DVT, for=20 dissolution of catheter-related thrombus, and for re-opening = of=20 occluded central lines and thrombosed dialysis=20 grafts.
Contrast venography used to guide duration = and=20 intensity of therapy.
Adult Dose For catheter-directed = treatment of=20 DVT: 5 mg bolus and 1 mg/h infusion for 12-24 h
For = infected=20 catheter thrombus or fibrin sleeve: 1 mg/h for 3 = h
For=20 occluded dialysis grafts: 10 mg bolus delivered into graft = site,=20 repeated q2h for 4 doses prn
Pediatric Dose Administer as in adults
Contraindications Documented = hypersensitivity; active=20 internal bleeding; cerebrovascular accident or stroke within = last 2=20 mo; intracranial or intraspinal surgery or trauma; = intracranial=20 hemorrhage on pretreatment evaluation; suspicion of = subarachnoid=20 hemorrhage, intracranial neoplasm, arteriovenous = malformation, or=20 aneurysm; bleeding diathesis; severe uncontrolled = hypertension
Interactions Drugs that alter platelet = function=20 (eg, aspirin, dipyridamole, abciximab) may increase risk of = bleeding=20 prior to, during, or after therapy; may give heparin with = and after=20 alteplase infusions to reduce risk of rethrombosis=97either = heparin or=20 alteplase may cause bleeding complications
Pregnancy C - Safety for use during = pregnancy=20 has not been established.=20
Precautions Monitor for bleeding, = especially at=20 arterial puncture sites, with coadministration of vitamin K=20 antagonists; control and monitor BP frequently during and = following=20 administration (when managing acute ischemic stroke); do not = use=20 >0.9 mg/kg to manage acute ischemic stroke; doses >0.9 = mg/kg=20 may cause ICH
Drug = Category:=20 Anticoagulants -- Anticoagulation with some form = of=20 heparin is essential in patients with septic phlebitis, but=20 anticoagulation alone does not guarantee a successful outcome. = Progression=20 of the disease may occur despite full and effective heparin=20 anticoagulation.=20

Heparin works by activating antithrombin III to slow or prevent = the=20 progression of venous thrombosis. Heparin does not dissolve = existing clot.=20

When low-molecular-weight heparin (LMWH) is used, checking the = aPTT has=20 no utility, because aPTT does not correlate with therapeutic = effect or=20 with bleeding risk in patients receiving LMWH.=20

When unfractionated heparin is used, an aPTT of at least 1.5 = times the=20 control value is necessary for a therapeutic effect. To achieve = this,=20 unfractionated heparin must be given IV in adequate doses. = Low-dose=20 subcutaneous unfractionated heparin should not be used, as it is = neither=20 an effective therapy for septic phlebitis nor an effective = prophylaxis=20 against progression of the disease.=20

Warfarin should not be used in the acute treatment of septic = phlebitis,=20 because the early risk of increased thrombogenesis outweighs any=20 convenience of oral therapy.
Drug Name
 Heparin (Hep-Lock) -- = Initial bolus=20 used for patients with inflammatory and septic thrombosis is = lower=20 than that needed for spontaneous DVT and PE, because most = patients=20 with inflammatory or septic thrombophlebitis do not have = underlying=20 hypercoagulability. Patients with DVT or PE require more = aggressive=20 therapy because DVT is manifestation of active = hypercoagulable=20 state.
Do not check aPTT until 6 h after initial = bolus of=20 unfractionated heparin, as extremely high or low value = during this=20 time should not provoke any action.
Adult Dose 60 U/kg (max 4000 U) IV = bolus,=20 followed by a 12 U/kg/h (max 1000 U/h) maintenance=20 infusion
After bolus, check aPTT every 6 h until = stable, and=20 adjust dosing as follows:
If aPTT is low (<1.5 = times=20 control value), rebolus with 4000 U and increase drip by 10% =
If=20 aPTT is high (>2.5 times control value), decrease drip=20 10%
If aPTT is extremely high (>100 sec), hold = heparin=20 drip for 1 h and decrease drip 10%
Pediatric Dose Administer as in adults
Contraindications Documented = hypersensitivity;=20 subacute bacterial endocarditis; active bleeding; history of = heparin-induced thrombocytopenia
Interactions Digoxin, nicotine, = tetracycline,=20 and antihistamines may decrease effects; NSAIDs, aspirin, = dextran,=20 dipyridamole, and hydroxychloroquine may increase toxicity
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Thromboembolism may occur = if dosing=20 inadequate; may cause hemorrhagic complications and can = trigger=20 immune thrombotic thrombocytopenia 1-2 wk after beginning = treatment;=20 platelet-consuming disseminated thrombosis refractory to = traditional=20 treatment can be fatal if not recognized quickly and managed = appropriately; if significant bleeding develops, 15 mg of = protamine=20 (infused over 3 min) usually reverses anticoagulant effect; = in=20 neonates, preservative-free heparin recommended to avoid = possible=20 toxicity (ie, gasping syndrome) by benzyl alcohol, which is = used as=20 preservative; caution in severe hypotension and = shock
Drug Name
 Enoxaparin (Lovenox) -- = First LMWH=20 released in US. Only LMWH now approved by FDA both for = treatment and=20 prophylaxis of DVT.
Widely used in pregnancy, = although=20 clinical trials not yet available to demonstrate that it is = as safe=20 as unfractionated heparin.
No utility in checking = aPTT (drug=20 has wide therapeutic window and aPTT does not correlate with = anticoagulant effect).
Adult Dose Thrombosis: 1 mg/kg SC=20 q12h
Prophylaxis: 30 mg SC q12h
Pediatric Dose Not established; = suggested dose 1.6=20 mg/kg SC bid if aged <2 months and 1 mg/kg/dose SC bid if = >2=20 months
Contraindications Documented = hypersensitivity; major=20 bleeding; thrombocytopenia
Interactions Platelet inhibitors or = oral=20 anticoagulants such as dipyridamole, salicylates, aspirin, = NSAIDs,=20 sulfinpyrazone, and ticlopidine may increase risk of = bleeding
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions If thromboembolic event = occurs=20 despite LMWH prophylaxis, discontinue drug and initiate = alternate=20 therapy; elevation of hepatic transaminases may occur but is = reversible; heparin-associated thrombocytopenia may occur = with=20 fractionated LMWH; 1 mg of protamine sulfate reverses effect = of=20 approximately 1 mg of enoxaparin if significant bleeding=20 complications develop
Drug Category:=20 Antibiotics -- Choice of antibiotic depends upon = results=20 of blood cultures or Gram stain and culture of material taken from = the=20 suppurative vessel or from a metastatic septic focus.=20

For superficial phlebitis, aerobic coverage is sufficient.=20

Anaerobic coverage is required for patients with abscess = formation,=20 those with pelvic or ovarian vein phlebitis, and those with = Lemierre=20 syndrome of internal jugular phlebitis (often due to F=20 necrophorum).=20

Candidal phlebitis is treated with amphotericin B.
Drug Name
 Penicillin G (Pfizerpen) = --=20 Interferes with synthesis of cell wall mucopeptide during = active=20 multiplication, resulting in bactericidal activity against=20 susceptible microorganisms. Aqueous penicillin G is first = choice for=20 treatment of susceptible infections because of its rapid = onset of=20 action.
Useful in infections of the head and neck due = to=20 Streptococcus, Clostridium, Actinomycosis, Listeria,=20 Erysipelothrix, and Pasteurella species as = well as=20 fusospirochetal infections.
Adult Dose 3-4 million U IV q4h
Pediatric Dose 30,000-40,000 U/kg q4h
Contraindications Documented = hypersensitivity
Interactions Probenecid can increase = effects;=20 tetracyclines can decrease effects; ethacrynic acid, = aspirin,=20 indomethacin, and furosemide may compete for renal tubular=20 secretion, resulting in increase in penicillin serum = concentrations
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Caution in impaired renal = function
Drug Name
 Clindamycin (Cleocin) --=20 Lincosamide for treatment of serious skin and soft-tissue=20 staphylococcal infections. Also effective against aerobic = and=20 anaerobic streptococci (except enterococci). Inhibits = bacterial=20 growth, possibly by blocking dissociation of peptidyl t-RNA = from=20 ribosomes, causing RNA-dependent protein synthesis to = arrest.
Adult Dose 150-300 mg IV q6h
Pediatric Dose 2-4 mg/kg IV = q6h
Severe=20 infections: 5 mg/kg IV q6h
Contraindications Documented = hypersensitivity;=20 regional enteritis; ulcerative colitis; hepatic impairment;=20 antibiotic-associated colitis
Interactions Increases duration of = neuromuscular=20 blockade induced by tubocurarine and pancuronium; = erythromycin may=20 antagonize effects; antidiarrheals may delay absorption
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Adjust dose in severe = hepatic=20 dysfunction; no adjustment necessary in renal insufficiency; = associated with severe and possibly fatal = colitis
Drug Name
 Metronidazole (Flagyl) -- = Imidazole=20 ring-based antibiotic active against various anaerobic = bacteria and=20 protozoa. Used in combination with other antimicrobial = agents=20 (except for Clostridium difficile enterocolitis).
Adult Dose Initial dose: 15 mg/kg IV = over 1=20 h
Subsequent doses: 7.5 mg/kg over 1 h q6-8h; not to = exceed 4=20 g in 24 h
Pediatric Dose 5-10 mg/kg IV q 8 h; not = to exceed=20 500 mg/dose
Contraindications Documented = hypersensitivity
Interactions Cimetidine may increase = toxicity;=20 may increase effects of anticoagulants; may increase = toxicity of=20 lithium and phenytoin; disulfiramlike reaction may occur = with orally=20 ingested ethanol
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Adjust dose in hepatic = disease;=20 monitor for seizures and development of peripheral=20 neuropathy
Drug Name
 Chloramphenicol = (Chloromycetin) --=20 Binds to 50 S bacterial-ribosomal subunits and inhibits = bacterial=20 growth by inhibiting protein synthesis. Effective against=20 gram-negative and gram-positive bacteria.
Adult Dose 12-25 mg/kg IV q6h; not = to exceed 4=20 g/d
Pediatric Dose 12-20 mg/kg IV q6h
Contraindications Documented = hypersensitivity
Interactions Barbiturates may decrease = serum=20 levels while barbiturate levels may increase, causing = toxicity;=20 sulfonylureas may cause manifestations of hypoglycemia; = rifampin may=20 reduce serum levels, presumably through hepatic enzyme = induction;=20 may increase effects of anticoagulants; may increase serum = hydantoin=20 levels, possibly resulting in toxicity and increasing or = decreasing=20 chloramphenicol levels
Pregnancy C - Safety for use during = pregnancy=20 has not been established.=20
Precautions Use only for indicated = infections,=20 or as prophylaxis for bacterial infections; serious and = fatal blood=20 dyscrasias (aplastic anemia, hypoplastic anemia, = thrombocytopenia,=20 granulocytopenia) can occur=97evaluate baseline and perform = periodic=20 blood studies approximately every 2 d while in therapy; = discontinue=20 upon appearance of reticulocytopenia, leukopenia, = thrombocytopenia,=20 anemia, or findings attributable to chloramphenicol; adjust = dose in=20 liver or kidney dysfunction; caution in pregnancy at term or = during=20 labor because of potential toxic effects on fetus (gray=20 syndrome)
Drug Name
 Amphotericin B (AmBisome) = --=20 Produced by strain of Streptomyces nodosus. Can be=20 fungistatic or fungicidal (effective against candidal = phlebitis).=20 Binds to sterols, such as ergosterol, in fungal cell = membrane,=20 causing intracellular components to leak with subsequent = fungal cell=20 death.
Adult Dose 3 mg/kg IV qd = administered over 2 h
Pediatric Dose Administer as in adults
Contraindications Documented = hypersensitivity
Interactions Antineoplastic agents may = enhance=20 potential for renal toxicity, bronchospasm, and hypotension; = corticosteroids, digitalis, and thiazides may potentiate=20 hypokalemia; cyclosporine increases risk of renal toxicity
Pregnancy B - Usually safe but = benefits must=20 outweigh the risks.=20
Precautions Monitor renal function, = serum=20 electrolytes such as magnesium and potassium, liver = function, CBC,=20 and hemoglobin concentrations; resume therapy at lowest = level (eg,=20 0.25 mg/kg) if interrupted for more than 7 d; hypoxemia, = acute=20 dyspnea, and interstitial infiltrates may occur in = neutropenic=20 patients receiving leukocyte transfusions (separate time of=20 amphotericin infusion from time of leukocyte=20 transfusion)

Further Outpatient Care:

  • Because septic phlebitis is associated with a high incidence = of=20 secondary endocarditis and other secondary endovascular = infection,=20 high-dose antibiotics are continued for at least 6 weeks after = blood=20 cultures become negative.

Deterrence/Prevention:

  • Peripheral septic phlebitis occurs more frequently after = cannulation=20 of lower limb veins. Therefore, this route should be used only = when=20 upper extremity veins are unavailable. Meticulously aseptic = technique=20 should be used for all IV cannulae.
  • Central lines (especially femoral lines) cause an = astonishingly high=20 incidence of deep vein thrombosis and of central line septic = thrombosis.=20 Central lines should be avoided in favor of peripheral lines = whenever=20 possible.
  FOLLOW-UP = Section 8 of = 10   <= IMG=20 height=3D10=20 alt=3D"Click here to go to the previous section in this = topic"=20 src=3D"http://www.emedicine.com/images/back3.gif" width=3D31 = align=3Dmiddle border=3D0>
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

Medical/Legal Pitfalls:

  MISCELLANEOUS = Section 9 of = 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography

  • Arnow PM, Quimosing EM, Beach M: Consequences of = intravascular=20 catheter sepsis. Clin Infect Dis 1993 Jun; 16(6): 778-84[Medline].=20
  • Collignon P, Sorrell T, Garret P: Are anaerobic bacteria = involved in=20 peripheral vein catheter associated thrombophlebitis? Biomed=20 Pharmacother 1988; 42(3): 213-5[Medline].=20
  • Feied CF: Venous disease of the extremities. In: Rosen P, = Barkin RM,=20 eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. = Mosby-Year Book; 1997.=20
  • Garrison RN, Richardson JD, Fry DE: Catheter-associated = septic=20 thrombophlebitis. South Med J 1982 Aug; 75(8): 917-9[Medline].=20
  • Khardori N, Yassien M: Biofilms in device-related = infections. J Ind=20 Microbiol 1995 Sep; 15(3): 141-7[Medline].=20
  • Lee BK, Lopez F, Genovese M, Loutit JS: Lemierre's syndrome. = South=20 Med J 1997 Jun; 90(6): 640-3[Medline].=20
  • Leonard JD, Printen KJ: Thrombophlebitis in the elderly. Am = Surg=20 1980 Aug; 46(8): 441-3[Medline].=20
  • Monreal M, Alastrue A, Rull M, et al: Upper extremity deep = venous=20 thrombosis in cancer patients with venous access = devices--prophylaxis=20 with a low molecular weight heparin (Fragmin). Thromb Haemost = 1996 Feb;=20 75(2): 251-3[Medline].=20
  • Pittet D, Hulliger S, Auckenthaler R: Intravascular = device-related=20 infections in critically ill patients. J Chemother 1995 Jul; 7 = Suppl 3:=20 55-66[Medline].=20
  • Plemmons RM, Dooley DP, Longfield RN: Septic = thrombophlebitis of the=20 portal vein (pylephlebitis): diagnosis and management in the = modern era.=20 Clin Infect Dis 1995 Nov; 21(5): 1114-20[Medline].=20
  • Seigel EL, Jew AC, Delcore R, et al: Thrombolytic therapy = for=20 catheter-related thrombosis. Am J Surg 1993 Dec; 166(6): 716-8;=20 discussion 718-9[Medline].=20
  • Strinden WD, Helgerson RB, Maki DG: Candida septic = thrombosis of the=20 great central veins associated with central catheters. Clinical = features=20 and management. Ann Surg 1985 Nov; 202(5): 653-8[Medline].=20
  • Twickler DM, Setiawan AT, Evans RS, et al: Imaging of = puerperal=20 septic thrombophlebitis: prospective comparison of MR imaging, = CT, and=20 sonography. AJR Am J Roentgenol 1997 Oct; 169(4): 1039-43[Medline].

  BIBLIOGRAPHY = Section 10 of=20 10   
Author=20 Information Introduction=20 Cli= nical=20 Differentials=20 Worku= p=20 Tr= eatment=20 M= edication=20 Fo= llow-up=20 Miscellaneous=20 Bibliography
NOTE: =
Medicine is a = constantly=20 changing science and not all therapies are clearly = established. New=20 research changes drug and treatment therapies daily. The = authors,=20 editors, and publisher of this journal have used their best = efforts=20 to provide information that is up-to-date and accurate and = is=20 generally accepted within medical standards at the time of=20 publication. However, as medical science is constantly = changing and=20 human error is always possible, the authors, editors, = and=20 publisher or any other party involved with the publication = of this=20 article do not warrant the information in this article is = accurate=20 or complete, nor are they responsible for omissions or = errors in the=20 article or for the results of using this information. The = reader=20 should confirm the information in this article from other = sources=20 prior to use. In particular, all drug doses, indications, = and=20 contraindications should be confirmed in the package = insert. FULL = DISCLAIMER=20

Thrombophlebitis,=20 Septic excerpt

=A9 Copyright 2003, eMedicine.com, = Inc.

About=20 Us | Privacy | = Terms=20 of Use | Contact Us | Advertise | Institutional=20 Subscribers
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3D"eMedicine
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EMERGENCY MEDICINE=0A= - Medical Reference
 
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Table of = Contents
Alphabetical Index of = Topics

Allergy = And Immunology
Cardiovascular
Dermatology
Ear, Nose, And Throat
Emergency Medical = Systems
Endocrine = And Metabolic
Environmental
Epidemiology
Gastrointestinal
Genitourinary
Hematology And = Oncology
Implantable = Devices
Infectious = Diseases
International = Emergency Medicine



Legal Aspects Of = Emergency Medicine
Managing The = Emergency Department
Neurology
Obstetrics And = Gynecology
Ophthalmology
Organizations In = Emergency Medicine
Pediatric
Psychosocial
Pulmonary
Rheumatology
Special = Aspects Of Emergency Medicine
Toxicology
Trauma And = Orthopedics
Warfare -=0A= Chemical, Biological, Radiological, Nuclear And Explosives
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Chief=0A= Editors
  Jonathan = Adler, MD
Barry Brenner, MD, PhD
Steven Dronen, MD
Craig Feied, = MD, FACEP, FAAEM
William K Mallon, MD
Robert O'Connor, MD, = MPH
Scott H Plantz, MD, FAAEM
Charles V Pollack, Jr, MD, = MA
Raymond J Roberge, MD, MPH, FAAEM, FACMT
=0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A= =0A=
Copy=0A= Editors
  Julie = Bohlen
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CME=0A= Editors
  John = Halamka, MD
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Pharmacy=0A= Editors
  Robert = Konop, PharmD
Francisco Talavera, PharmD, PhD
John T VanDeVoort, = PharmD, DABAT
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Medical=0A= Editors
 Roy Alson, = MD, PhD
Jerry Balentine, DO
Kirsten Bechtel, MD
Michael S = Beeson, MD, MBA
Edward Bessman, MD
Jeffrey Glenn Bowman, MD, = MS
David FM Brown, MD
William Chiang, MD
Steven A Conrad, MD, = PhD
Francis Counselman, MD
Dan Danzl, MD
Peter MC DeBlieux, = MD
Daniel J Dire, MD, FACEP, FAAEM
Michelle Ervin, MD
Miguel C = Fernandez, MD
Theodore Gaeta, DO, MPH
Michael Glick, = DMD
William Gossman, MD
Robin R Hemphill, MD
Fred Henretig, = MD
Edmond Hooker, MD
B Zane Horowitz, MD
David S Howes, = MD
Eric Kardon, MD
James E Keany, MD, FACEP
Samuel M Keim, = MD
Mark Keim, MD
Richard S Krause, MD
Lance W Kreplick, MD, = MMM
Richard Lavely, MD, JD, MS, MPH
David C Lee, MD
James Li, = MD
William Lober, MD
Mark Louden, MD, FAAEM
Robert M McNamara, = MD, FAAEM
Edward A Michelson, MD
Jerry L Mothershead, MD
Jerome = FX Naradzay, MD, FACEP
Robert Norris, MD
David A Peak, = MD
Joseph J Sachter, MD, FACEP
Joseph A Salomone III,=0A= MD
Assaad J Sayah, MD
Mark S Slabinski, MD
Debra Slapper, = MD
Dana A Stearns, MD
Suzanne White, MD
Garry Wilkes, MD
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Managing=0A= Editors
  Jeffrey L = Arnold, MD, FACEP, FAAEM
John Benitez, MD, MPH, FACMT
Howard A = Bessen, MD
Paul Blackburn, DO
Michael J Burns, MD
Robert G = Darling, MD
David Eitel, MD, MBA
Gino A Farina, MD
Mark W = Fourre, MD
Jonathan A Handler, MD
Fred Harchelroad, MD, = FACMT
Eugene Hardin, MD
Robert C Harwood, MD, MPH
Jon Mark = Hirshon, MD, MPH
Michael Hodgman, MD
J Stephen Huff, MD
Amin = Antoine Kazzi, MD
Eddy Lang, MDCM, CCFP (EM), CSPQ
Douglas = Lavenburg, MD
Eric Legome, MD
David Levy, DO
Mark L Plaster, = MD, JD
Matthew M Rice, MD, JD
Tom Scaletta, MD
Gary Setnik, = MD
Barry J Sheridan, DO
Richard Sinert, DO
Jeter (Jay) = Pritchard Taylor III, MD
James S Walker, DO
Eric L Weiss, MD, = DTM&H
Wayne Wolfram, MD, MPH
Grace M Young, MD
Mark Zwanger, = MD, MBA


Article = Excerpts
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