Septic Thrombophlebitis Treatment & Management

  • Author: Nicholas Connors, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 10, 2010
 

Prehospital Care

No specific prehospital care is required for septic thrombophlebitis.

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Emergency Department Care

Peripheral

Peripheral intravenous catheters should be removed at the first sign of erythema, induration, or edema.[3] The temptation to try to preserve a peripheral intravenous catheter must be resisted, because complications associated with septic phlebitis are substantial and increase dramatically over time if the catheter is left in place.

Once phlebitis has become suppurative, simply removing the cannula is no longer sufficient. Inpatient surgical resection of the involved vein and its emissaries is the treatment of choice. Broad-spectrum antibiotics to cover S aureus, streptococci, and Enterobacteriaceae should be administered if suppuration or infection are noted. Polymicrobial infections are particularly common in burn patients.

Associated abscesses should be incised and drained.

Central

In contrast to peripheral venous catheters, infected central venous catheters should not be removed precipitously. Infected and thrombosed central catheters often have an extensive infected free-floating fibrin sheath, and a large mass of septic thrombus may be attached to the catheter. If the catheter is withdrawn precipitously, this septic material may embolize to cause infarct and distant septic metastases. Fibrinolysis is often necessary before safe removal can be undertaken.

Broad-spectrum antibiotics are indicated. In the case of Lemierre's syndrome, particular attention should be paid to covering anaerobic infections, whereas intra-abdominal septic thrombosis requires coverage of gram-negative organisms and anaerobes. Duration of therapy for all central venous disease is usually 4-6 weeks. Because many infections are due to S aureus, coverage of MRSA should be seriously considered depending on local resistance patterns.

Anticoagulation with heparin has been recommended for most central venous thrombophlebitides. The course of septic pelvic thrombophlebitis is notably improved with anticoagulation,[35] though there is no proven benefit in pylephlebitis. Its role in Lemierre's syndrome also remains controversial.[11] Anticoagulation does have an associated benefit in dural sinus thrombophlebitis, but no prospective data exist.[11]

Surgical excision of the involved vein is not possible in these cases, but resection of the infected thrombus may sometimes be necessary as an inpatient if the patient does not respond to medical management.

Associated abscesses should be incised and drained, surgically if in the deep tissues.[10, 15]

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Consultations

  • Surgery/vascular: Well-localized superficial phlebitis, even if suppurative, does not require any consultation provided the emergency physician is capable of performing superficial phlebectomy if indicated. However, patients with widespread suppurative phlebitis or suppurative phlebitis threatening the deep venous system benefit from consultation with a vascular surgeon. Additionally, the expertise of a general surgeon, gynecologist, otorhinolaryngologist, or neurosurgeon may be indicated, depending on each patient’s focus of infection and metastatic spread.
  • Interventional radiology: Patients with thrombosed and infected central lines benefit from fibrinolysis and antibiotics prior to removal of the catheter. Because emergency physicians cannot often carry out this fibrinolysis due to hospital-specific time and expertise constraints, consultation with an interventional radiologist may be indicated.
  • Infectious disease: Consultation with an infectious disease specialist may be prudent, in particular when dealing with immunocompromised patients.
  • Intensive care: ICU consultation is required when clinically warranted.
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Contributor Information and Disclosures
Author

Nicholas Connors, MD  Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital, University Hospital of Cornell and Columbia

Disclosure: Nothing to disclose.

Coauthor(s)

Juliet D Caldwell, MD  Assistant Professor, Department of Emergency Medicine, Weill Cornell Medical College; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital, Weill-Cornell Medical Center; Attending Physician, Department of Emergency Medicine, Long Island College Hospital

Juliet D Caldwell, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Craig F Feied, MD, Jonathan A Handler, MD, and Christian Theodosis, MD, to the development and writing of this article.

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