eMedicine Specialties > Emergency Medicine > Infectious Diseases

Thrombophlebitis, Septic: Follow-up

Author: Christian Theodosis, MD, MPH, Resident Physician, Section of Emergency Medicine, Yale School of Medicine
Coauthor(s): Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group; Jonathan A Handler, MD, Director of Informatics, Assistant Professor, Department of Emergency Medicine, Northwestern Memorial Hospital
Contributor Information and Disclosures

Updated: Jul 24, 2009

Follow-up

Further Outpatient Care

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

Deterrence/Prevention

  • True prevention
    • As is the case for most clinically apparent illnesses, many cases of septic thrombophlebitis could be prevented. A substantial body of evidence exists mandating early removal and replacement of central and peripheral catheters. A similar body of knowledge underlies the importance of sterile technique, which should always be used when physicians perform procedures that involve disruption of the patient's skin.
    • This being said, studies suggest that deviation from standard best practices is common. It cannot be overemphasized that meticulous attention to sterile technique and early replacement of access devices are key strategies the physician must use in order to manage this problem successfully.
  • Mitigation
    • Peripheral septic phlebitis occurs more frequently after cannulation of lower limb veins. Therefore, this route should be used only when upper extremity veins are unavailable. Meticulously aseptic technique should be used for all intravenous cannulae.
    • Central lines (especially femoral lines) are associated with deep vein thrombosis and central venous septic thrombophlebitis. Central lines should be avoided in favor of peripheral lines whenever possible.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose and treat thrombophlebitis in a rapid and appropriate manner leads to poor patient outcomes and to substantial legal liability. Most allegations of mismanagement fall into one of a small number of categories.
    • Failure to suspect the diagnosis when a reasonable physician would have suspected it
    • Considering the diagnosis but failing to pursue the diagnostic workup despite the fact that clinical diagnosis alone is known to be inadequate
    • Beginning a diagnostic workup but failing to pursue the workup to completion (Once a workup has been initiated, abandoning the workup without a definitive diagnosis is not acceptable.)
    • Making the diagnosis but failing to institute appropriate treatment in a timely manner
    • Failing to recognize that a patient is getting worse instead of better, especially when the patient has returned for a second or even a third visit

Special Concerns

  • Recent case reports and controversies
    • Recent case reports - Amiodarone, propofol
      • Amiodarone: Long-standing controversies exist over whether or not various medicines may cause phlebitis when infused, particularly when infused into small peripheral veins. General consensus has been that amiodarone is one such medicine. A case report by Aljitawi et al (2005) again documented a case of superficial phlebitis related to amiodarone administered peripherally.5 Whether or not amiodarone is the culprit remains controversial, but the preponderance of evidence suggests that the clinician should opt for the PO route when possible or for the central venous route when PO is not clinically appropriate.
      • Propofol: Propofol is a medicine that has historically been formulated in a lipid-based diluent. Last year, an alternate formulation of propofol was available in some markets in aqueous diluent. A case report by Dubey and Kumar (2005) reported a case of acute phlebitis that may have been related to this new formulation.6 No definitive studies on the matter are available, but the clinician should be aware that acute phlebitis may occur and one's index of suspicion must be high, particularly when administering new formulations of medicines.
    • A case of cryptogenic septic shock
      • It is understood that surgical debridement and excision may be indicated for clinically apparent and surgically amenable cases of superficial thrombophlebitis. A case report by Katz et al (2005) described a case in which a multiply injured trauma patient was found to have prolonged and unexplained shock.7 The treating physicians ultimately determined it had been caused by a superficial septic thrombophlebitis that had not been detected early. They reported that excision produced a prompt improvement in the patient's clinical condition.
      • This case raises the importance not only of appropriate management for clinically apparent illness but also emphasizes that efforts should be made to rule out septic thrombophlebitis in patients who are at risk.
 


More on Thrombophlebitis, Septic

Overview: Thrombophlebitis, Septic
Differential Diagnoses & Workup: Thrombophlebitis, Septic
Treatment & Medication: Thrombophlebitis, Septic
Follow-up: Thrombophlebitis, Septic
References
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References

  1. Rosado P, Gallego L, Junquera L, de Vicente JC. Lemierre's Syndrome: a serious complication of an odontogenic infection. Med Oral Patol Oral Cir Bucal. Mar 20 2009;[Medline].

  2. Lee BK, Lopez F, Genovese M, Loutit JS. Lemierre's syndrome. South Med J. Jun 1997;90(6):640-3. [Medline].

  3. David H. A 21-year-old man with fever and abdominal pain after recent peritonsillar abscess drainage. Am J Emerg Med. May 2009;27(4):515.e3-4. [Medline].

  4. Block AA, Thursky KA, Worth LJ, Slavin MA. Thrombolytic therapy for management of complicated catheter-related Candida albicans thrombophlebitis. Intern Med J. Jan 2009;39(1):61-3. [Medline].

  5. Aljitawi O, Shabaneh B, Whitaker J. Bilateral upper extremity thrombophlebitis related to intravenous amiodarone: a case report. South Med J. Aug 2005;98(8):814-6. [Medline].

  6. Dubey PK, Kumar A. Vascular complication following lipid free propofol injection. J Postgrad Med. Jan-Mar 2005;51(1):73-4. [Medline].

  7. Katz SC, Pachter HL, Cushman JG. Superficial septic thrombophlebitis. J Trauma. Sep 2005;59(3):750-3. [Medline].

  8. Arnow PM, Quimosing EM, Beach M. Consequences of intravascular catheter sepsis. Clin Infect Dis. Jun 1993;16(6):778-84. [Medline].

  9. Collignon P, Sorrell T, Garret P. Are anaerobic bacteria involved in peripheral vein catheter associated thrombophlebitis?. Biomed Pharmacother. 1988;42(3):213-5. [Medline].

  10. Feied CF. Venous disease of the extremities. In: Rosen P, Barkin RM, eds. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby-Year Book; 1997.

  11. Garrison RN, Richardson JD, Fry DE. Catheter-associated septic thrombophlebitis. South Med J. Aug 1982;75(8):917-9. [Medline].

  12. Khardori N, Yassien M. Biofilms in device-related infections. J Ind Microbiol. Sep 1995;15(3):141-7. [Medline].

  13. Leonard JD, Printen KJ. Thrombophlebitis in the elderly. Am Surg. Aug 1980;46(8):441-3. [Medline].

  14. Monreal M, Alastrue A, Rull M, et al. Upper extremity deep venous thrombosis in cancer patients with venous access devices--prophylaxis with a low molecular weight heparin (Fragmin). Thromb Haemost. Feb 1996;75(2):251-3. [Medline].

  15. Pittet D, Hulliger S, Auckenthaler R. Intravascular device-related infections in critically ill patients. J Chemother. Jul 1995;7 Suppl 3:55-66. [Medline].

  16. Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis. Nov 1995;21(5):1114-20. [Medline].

  17. Seigel EL, Jew AC, Delcore R, et al. Thrombolytic therapy for catheter-related thrombosis. Am J Surg. Dec 1993;166(6):716-8; discussion 718-9. [Medline].

  18. Strinden WD, Helgerson RB, Maki DG. Candida septic thrombosis of the great central veins associated with central catheters. Clinical features and management. Ann Surg. Nov 1985;202(5):653-8. [Medline].

  19. Tilton D. Central venous access device infections in the critical care unit. Crit Care Nurs Q. Apr-Jun 2006;29(2):117-22. [Medline].

  20. Twickler DM, Setiawan AT, Evans RS, et al. Imaging of puerperal septic thrombophlebitis: prospective comparison of MR imaging, CT, and sonography. AJR Am J Roentgenol. Oct 1997;169(4):1039-43. [Medline].

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Further Reading

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Keywords

septic phlebitis, septic thrombophlebitis, septic emboli, septic shock, catheter-related septic phlebitis, suppurative superficial thrombophlebitis, septic pelvic thrombophlebitis, septic ovarian vein thrombophlebitis, septic pelvic phlebitis, Lemierre syndrome

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Contributor Information and Disclosures

Author

Christian Theodosis, MD, MPH, Resident Physician, Section of Emergency Medicine, Yale School of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group
Craig F Feied, MD, FACEP, FAAEM, FACPh is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Phlebology, American College of Physicians, American Medical Association, American Medical Informatics Association, American Venous Forum, Medical Society of the District of Columbia, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Jonathan A Handler, MD, Director of Informatics, Assistant Professor, Department of Emergency Medicine, Northwestern Memorial Hospital
Jonathan A Handler, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eddy Lang, MDCM, CCFP (EM), CSPQ, Assistant Professor, Department of Family Medicine, McGill University; Consulting Staff, Department of Emergency Medicine, The Sir Mortimer B Davis-Jewish General Hospital
Eddy Lang, MDCM, CCFP (EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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