Approach Considerations
Given the rarity of septic thrombophlebitis, as well as the wide variety of vessels involved and the substantial morbidity and mortality, a very high index of suspicion should be maintained by the ED physician.
Prehospital Care
No specific prehospital care is required for septic thrombophlebitis.
Emergency and Inpatient Department Care
Peripheral septic thrombophlebitis
Peripheral intravenous catheters should be removed at the first sign of erythema, induration, or edema. [4] 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. Broad-spectrum antibiotics to cover S aureus, streptococci, and Enterobacteriaceae should be administered. Vancomycin may be used to cover community- and hospital-acquired methicillin-resistant S aureus (MRSA), as well as methicillin-sensitive S aureus (MSSA), and streptococci. Ceftriaxone is a good agent to add for its activity against Enterobacteriaceae, although other cephalosporins are also useful. Remember that polymicrobial infections are especially common in burn patients, and antibiotic treatment should be accordingly broad spectrum. Duration of intravenous therapy can be as short as 7 days, although courses tend to be longer, with the median from one sample of 19.5 days. Oral antibiotics should follow. [38]
Associated abscesses should be incised and drained, and surgical resection of the involved vein and its emissaries is definitive treatment when antibiotics alone have proven insufficient. Larger veins, such as the femoral vein, are more difficult or impossible to excise and are treated conservatively with IV antibiotics, like the pelvic veins. [39]
The role of anticoagulation is uncertain and should not be routinely used unless extension of thrombus is evident.
SVC and IVC septic thrombophlebitis
These deep venous infections are almost always the result of central venous catheterization. In contrast to peripheral venous catheters, infected central venous cannulas should not be removed immediately. 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 If the catheter is withdrawn precipitously, this septic material may embolize to cause infarct and distant septic metastases.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 sometimes necessary before safe removal can be undertaken.
Broad-spectrum antibiotics are indicated for at least 3-4 weeks. S aureus, followed by streptococci and Enterobacteriaceae, are again the most common organisms, and good empiric antimicrobial choices include vancomycin for gram-positive coverage and a fourth-generation cephalosporin, carbapenem, beta-lactam/beta-lactamase combination, with or without an aminoglycoside, for gram-negative coverage. [1] Coverage for Pseudomonas aeruginosa should be added in patients who are neutropenic or who have severe sepsis. [1] Further antibiotic treatment should be guided by blood culture and sensitivity results. Fungal bacteremia is more common in central catheter–associated thrombophlebitis, particularly in patients receiving total parenteral nutrition (TPN), and can usually be covered by the addition of intravenous fluconazole.
Anticoagulation is often favored in deep vein disease, although no controlled studies have been performed to date. Studies of central venous thrombophlebitis report success with streptokinase, heparin, and enoxaparin. [40]
Internal jugular thrombophlebitis
In the case of Lemierre syndrome, particular attention should be paid to covering anaerobic infections especially F necrophorum, as well as streptococci and Bacteroides species. Empiric antibiotic therapy should include a beta-lactamase–resistant B-lactam to cover F necrophorum since penicillin failure has been reported. [41] Ampicillin-sulbactam, piperacillin-tazobactam, or a carbapenem are all good choices. Duration of intravenous therapy is prolonged, for a duration of at least 3-4 weeks.
The role of anticoagulation in infected jugular vein thrombosis is controversial. [12] Catheter-directed thrombolysis may be an option. [42]
Incision and drainage of adjacent peritonsillar abscess should be performed promptly by an otolaryngological surgeon or trained ED specialist. [10] Surgical resection of infected thrombus is generally reserved in case conservative management fails.
Portal, pelvic, and other intra-abdominal thrombophlebitides
Antibiotic selection for intra-abdominal septic thrombosis requires coverage of Gram-negative organisms and anaerobes. The disease course of septic pelvic thrombophlebitis is improved with anticoagulation, [43] although there is no proven benefit in pylephlebitis. Surgical thrombectomies are again typically reserved for cases that fail conservative management.
Dural sinus thrombophlebitides
Broad antibiotic coverage must be implemented as soon as possible given the devastating outcomes in this disease. The majority of infections are, in fact, due to S aureus, [20, 21] and coverage of MRSA should be routinely instituted in dural sinus phlebitis. Vancomycin is a good initial choice, though rifampin might be added to increased cerebrospinal fluid penetrance. Streptococci and anaerobes should also be covered, particularly in the setting of associated sinus, dental, or ear infection, with the addition of a third- or fourth-generation cephalosporin (ceftriaxone or cefepime) plus an agent like metronidazole for anaerobic coverage. Duration of antimicrobial therapy for all central venous disease is usually 4-6 weeks.
The role of anticoagulation in septic dural vein thrombosis remains controversial.
Consultations
Surgical/vascular
Well-localized superficial phlebitis, even if suppurative, does not routinely require any consultation. However, patients with widespread suppurative phlebitis or suppurative phlebitis threatening the deep venous system may benefit from consultation with a vascular surgeon. Additionally, the expertise of a general surgeon, gynecologist, otorhinolaryngologist, or neurosurgeon may be indicated, depending on the patient’s focus of infection.
Interventional radiology
Patients with thrombosed and infected central lines can benefit from fibrinolysis prior to removal of the catheter, and consultation with an interventional radiologist may be indicated, although this is often done in an inpatient setting.
Infectious disease
Consultation with an infectious disease specialist may be prudent, particularly when dealing with immunocompromised patients.
Intensive care
Intensive care unit (ICU) consultation is required when clinically warranted.
Outpatient Care
Outpatient care should be determined on discharge by the admitting team and may include oral antibiotics. Surveillance for endocarditis and recurrent septic phlebitis should be implemented, since these secondary outcomes are not uncommon.
Deterrence and Prevention
Deterrence and prevention measures include the following:
