Suppurative thrombophlebitis medical therapy: Difference between revisions
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{{Suppurative thrombophlebitis}} | {{Suppurative thrombophlebitis}} | ||
{{CMG}} | {{CMG}} | ||
==Overview== | |||
The mainstay of therapy for suppurative thrombophlebitis is antimicrobial therapy. Empiric therapy includes anti-staphylococcal antibiotics plus antibiotics with coverage against ''[[enterobacteriaceae]]''. The benefit of pharmacologic [[anticoagulation]] is uncertain in suppurative thrombophlebitis and is not routinely recommended. | |||
==Medical Therapy== | ==Medical Therapy== | ||
* The mainstay of therapy for suppurative thrombophlebitis is a prolonged course of targeted antibiotic therapy. | |||
* Duration of therapy is at least 4 weeks for all cases regardless of the causative organism. Patients may need 6 weeks of therapy to clear the infection. | |||
=== | * Any long-term catheters should be removed from patients with suppurative thrombophlebitis. It is recommended that no long-term catheters are inserted before clearing of blood cultures. | ||
{| | * All recommendations are based on observational data. There is no randomized data to determine the optimal duration of antibiotics, use of anticoagulants, thrombolytic agents, or excision of the involved vessel. | ||
| | * The use of anticoagulants remains controversial, but anticoagulation with heparin should be considered in refractory cases.<ref name="pmid19489710">{{cite journal| author=Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP et al.| title=Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2009 | volume= 49 | issue= 1 | pages= 1-45 | pmid=19489710 | doi=10.1086/599376 | pmc=PMC4039170 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19489710 }} </ref> | ||
{ | ===Antimicrobial Regimens=== | ||
* '''Treatment of suppurative thrombophlebitis'''<ref name="pmid19489710">{{cite journal| author=Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP et al.| title=Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2009 | volume= 49 | issue= 1 | pages= 1-45 | pmid=19489710 | doi=10.1086/599376 | pmc=PMC4039170 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19489710 }} </ref> | |||
:* '''1. Bacterial pathogens''' | |||
::* '''1.1 Gram-positive bacilli''' | |||
:::* '''1.1.1 Staphylococcus aureus''' | |||
::::* '''1.1.1.1 Methicillin-sensitive''' | |||
:::::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h | |||
:::::* Alternative regimen: [[Cefazolin]] 2 g IV q8h {{or}} [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
::::* '''1.1.1.2 Methicillin-resistant''' | |||
:::::* Preferred regimen: [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
:::::* Alternative regimen (1): [[Daptomycin]] 6-8 mg/kg/day IV q24h {{or}} [[Linezolid]] 600 mg IV q12h | |||
:::::* Alternative regimen (2): [[Trimethoprim-sulfamethoxazole]] 3–5 mg/kg PO/IV q8h | |||
:::* '''1.1.2 Coagulase-negative staphylococci''' | |||
::::* '''1.1.2.1 Methicillin-sensitive''' | |||
:::::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h | |||
:::::* Alternative regimen: [[Cefazolin]] 2 g IV q8h {{or}} [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
::::* '''1.1.2.2 Methicillin-resistant''' | |||
:::::* Preferred regimen: [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
:::::* Alternative regimen: [[Daptomycin]] 6-8 mg/kg/day IV q24h {{or}} [[Linezolid]] 600 mg IV q12h {{or}} [[Quinupristin]]/[[Dalfopristin]] 7.5 mg/kg IV q8h | |||
:::::* Note: Linezolid-resistant strains have been reported | |||
:::* '''1.1.3 Enterococcus faecalis & Enterococcus faecium''' | |||
::::* '''1.1.3.1 Ampicillin-sensitive''' | |||
:::::* Preferred regimen: [[Ampicillin]] 2 g IV q4-6h '''±''' [[Gentamicin]] 1 mg/kg IV q8h | |||
:::::* Alternative regimen: [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
::::* '''1.1.3.2 Ampicillin-resistant & Vancomycin-sensitive''' | |||
:::::* Preferred regimen: [[Ampicillin]] 2 g IV q4-6h {{and}} [[Gentamicin]] 1 mg/kg IV q8h | |||
:::::* Alternative regimen: [[Daptomycin]] 6-8 mg/kg/day IV q24h {{or}} [[Linezolid]] 600 mg IV q12h | |||
::::* '''1.1.3.3 Ampicillin-resistant & Vancomycin-resistant''' | |||
:::::* Preferred regimen: [[Daptomycin]] 6-8 mg/kg/day IV q24h {{or}} [[Linezolid]] 600 mg IV q12h | |||
:::::* Alternative regimen: [[Quinupristin]]/[[Dalfopristin]] 7.5 mg/kg IV q8h | |||
:::::* Note: Quinupristin/Dalfopristin is not effective against E. faecalis | |||
::* '''1.2 Gram-negative bacilli''' | |||
:::* '''1.2.1 Escherichia coli & Klebsiella spp.''' | |||
::::* '''1.2.1.1 ESBL negative''' | |||
:::::* Preferred regimen: [[Ceftriaxone]] 1-2 g IV q24h | |||
:::::* Alternative regimen: [[Ciprofloxacin]] 400 mg IV q8-12h {{or}} [[Aztreonam]] 1-2 g IV q6-12h (maximum dose 8 g/day) | |||
::::* '''1.2.1.2 ESBL positive''' | |||
:::::* Preferred regimen: [[Ertapenem]] 1 g IV/IM q24h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Doripenem]] 500 mg IV q8h | |||
:::::* Alternative regimen: [[Ciprofloxacin]] 400 mg IV q8-12h {{or}} [[Aztreonam]] 1-2 g IV q6-12h (maximum dose 8 g/day) | |||
:::* '''1.2.2 Enterobacter spp. & Serratia marcescens''' | |||
::::* Preferred regimen: [[Ertapenem]] 1 g IV/IM q24h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h | |||
::::* Alternative regimen: [[Cefepime]] 1-2 g IV q8-12h {{or}} [[Ciprofloxacin]] 400 mg IV q8-12h | |||
:::* '''1.2.3 Acinetobacter spp.''' | |||
::::* Preferred regimen: [[Ampicillin-Sulbactam]] 1.5-3 g IV/IM q6h {{or}} [[Ertapenem]] 1 g IV/IM q24h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Doripenem]] 500 mg IV q8h | |||
:::* '''1.2.4 Stenotrophomonas maltophilia''' | |||
::::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] 3–5 mg/kg PO/IV q8h | |||
::::* Alternative regimen: [[Ticarcillin-Clavulanate]] 3.1 g IV q4-6h | |||
:::* '''1.2.5 Pseudomonas aeruginosa''' | |||
::::* Preferred regimen: [[Cefepime]] 1-2 g IV q8-12h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Amikacin]] 15 mg/kg IV q24h or [[Tobramycin]] 5–7 mg/kg IV q24h | |||
:::* '''1.2.6 Burkholderia cepacia''' | |||
::::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] 3–5 mg/kg PO/IV q8h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h | |||
:* '''2. Fungal pathogens''' | |||
::* '''2.1 Candida spp.''' | |||
:::* Preferred regimen (1): [[Caspofungin]] 70 mg IV single dose {{then}} 50 mg IV q24h | |||
:::* Preferred regimen (2): [[Micafungin]] 100 mg IV q24h | |||
:::* Preferred regimen (3): [[Anidulafungin]] 200 mg IV single dose {{then}} 100 mg IV q24h | |||
:::* Preferred regimen (4): [[Fluconazole]] 400–600 mg IV q24h | |||
:::* Alternative regimen: [[Amphotericin B]], Liposomal 3-5 mg/kg IV q24h | |||
:* '''3. Uncommon pathogens''' | |||
::* '''3.1 Corynebacterium jeikeium''' | |||
:::* Preferred regimen: [[Vancomycin]] 15 mg/kg q12h (trough levels 15-20 mcg/ml) | |||
:::* Alternative regimen: [[Linezolid]] 600 mg IV q12h | |||
:::* Note: No clinical studies available for Linezolid. Recommendation based on ''in vitro'' activity. | |||
::* '''3.2 Chryseobacterium (Flavobacterium) spp.''' | |||
:::* Preferred regimen: [[Levofloxacin]] 750 mg IV q24h | |||
:::* Alternative regimen: [[Trimethoprim-Sulfamethoxazole]] 3–5 mg/kg PO/IV q8h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h | |||
::* '''3.3 Ochrobacterium anthropi''' | |||
:::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] 3–5 mg/kg PO/IV q8h {{or}} [[Ciprofloxacin]] 400 mg IV q8-12h | |||
:::* Alternative regimen: ([[Ertapenem]] 1 g IV/IM q24h {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 1 g IV q8h {{or}} [[Doripenem]] 500 mg IV q8h) {{and}} [[Gentamicin]] 1 mg/kg IV q8h | |||
::* '''3.4 Malassezia furfur''' | |||
:::* Preferred regimen: [[Amphotericin B]], Liposomal 3-5 mg/kg IV q24h | |||
:::* Alternative regimen: [[Voriconazole]] 6 mg/kg IV q12h for first 24h {{then}} 4 mg/kg IV q12h | |||
==References== | ==References== | ||
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[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category: | [[Category:Infectious Disease Project]] | ||
Latest revision as of 00:21, 30 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The mainstay of therapy for suppurative thrombophlebitis is antimicrobial therapy. Empiric therapy includes anti-staphylococcal antibiotics plus antibiotics with coverage against enterobacteriaceae. The benefit of pharmacologic anticoagulation is uncertain in suppurative thrombophlebitis and is not routinely recommended.
Medical Therapy
- The mainstay of therapy for suppurative thrombophlebitis is a prolonged course of targeted antibiotic therapy.
- Duration of therapy is at least 4 weeks for all cases regardless of the causative organism. Patients may need 6 weeks of therapy to clear the infection.
- Any long-term catheters should be removed from patients with suppurative thrombophlebitis. It is recommended that no long-term catheters are inserted before clearing of blood cultures.
- All recommendations are based on observational data. There is no randomized data to determine the optimal duration of antibiotics, use of anticoagulants, thrombolytic agents, or excision of the involved vessel.
- The use of anticoagulants remains controversial, but anticoagulation with heparin should be considered in refractory cases.[1]
Antimicrobial Regimens
- Treatment of suppurative thrombophlebitis[1]
- 1. Bacterial pathogens
- 1.1 Gram-positive bacilli
- 1.1.1 Staphylococcus aureus
- 1.1.1.1 Methicillin-sensitive
- Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- Alternative regimen: Cefazolin 2 g IV q8h OR Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- 1.1.1.2 Methicillin-resistant
- Preferred regimen: Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- Alternative regimen (1): Daptomycin 6-8 mg/kg/day IV q24h OR Linezolid 600 mg IV q12h
- Alternative regimen (2): Trimethoprim-sulfamethoxazole 3–5 mg/kg PO/IV q8h
- 1.1.2 Coagulase-negative staphylococci
- 1.1.2.1 Methicillin-sensitive
- Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
- Alternative regimen: Cefazolin 2 g IV q8h OR Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- 1.1.2.2 Methicillin-resistant
- Preferred regimen: Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- Alternative regimen: Daptomycin 6-8 mg/kg/day IV q24h OR Linezolid 600 mg IV q12h OR Quinupristin/Dalfopristin 7.5 mg/kg IV q8h
- Note: Linezolid-resistant strains have been reported
- 1.1.3 Enterococcus faecalis & Enterococcus faecium
- 1.1.3.1 Ampicillin-sensitive
- Preferred regimen: Ampicillin 2 g IV q4-6h ± Gentamicin 1 mg/kg IV q8h
- Alternative regimen: Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- 1.1.3.2 Ampicillin-resistant & Vancomycin-sensitive
- Preferred regimen: Ampicillin 2 g IV q4-6h AND Gentamicin 1 mg/kg IV q8h
- Alternative regimen: Daptomycin 6-8 mg/kg/day IV q24h OR Linezolid 600 mg IV q12h
- 1.1.3.3 Ampicillin-resistant & Vancomycin-resistant
- Preferred regimen: Daptomycin 6-8 mg/kg/day IV q24h OR Linezolid 600 mg IV q12h
- Alternative regimen: Quinupristin/Dalfopristin 7.5 mg/kg IV q8h
- Note: Quinupristin/Dalfopristin is not effective against E. faecalis
- 1.2 Gram-negative bacilli
- 1.2.1 Escherichia coli & Klebsiella spp.
- 1.2.1.1 ESBL negative
- Preferred regimen: Ceftriaxone 1-2 g IV q24h
- Alternative regimen: Ciprofloxacin 400 mg IV q8-12h OR Aztreonam 1-2 g IV q6-12h (maximum dose 8 g/day)
- 1.2.1.2 ESBL positive
- 1.2.2 Enterobacter spp. & Serratia marcescens
- Preferred regimen: Ertapenem 1 g IV/IM q24h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h
- Alternative regimen: Cefepime 1-2 g IV q8-12h OR Ciprofloxacin 400 mg IV q8-12h
- 1.2.3 Acinetobacter spp.
- Preferred regimen: Ampicillin-Sulbactam 1.5-3 g IV/IM q6h OR Ertapenem 1 g IV/IM q24h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h
- 1.2.4 Stenotrophomonas maltophilia
- Preferred regimen: Trimethoprim-Sulfamethoxazole 3–5 mg/kg PO/IV q8h
- Alternative regimen: Ticarcillin-Clavulanate 3.1 g IV q4-6h
- 1.2.5 Pseudomonas aeruginosa
- Preferred regimen: Cefepime 1-2 g IV q8-12h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Amikacin 15 mg/kg IV q24h or Tobramycin 5–7 mg/kg IV q24h
- 1.2.6 Burkholderia cepacia
- Preferred regimen: Trimethoprim-Sulfamethoxazole 3–5 mg/kg PO/IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h
- 2. Fungal pathogens
- 2.1 Candida spp.
- Preferred regimen (1): Caspofungin 70 mg IV single dose THEN 50 mg IV q24h
- Preferred regimen (2): Micafungin 100 mg IV q24h
- Preferred regimen (3): Anidulafungin 200 mg IV single dose THEN 100 mg IV q24h
- Preferred regimen (4): Fluconazole 400–600 mg IV q24h
- Alternative regimen: Amphotericin B, Liposomal 3-5 mg/kg IV q24h
- 3. Uncommon pathogens
- 3.1 Corynebacterium jeikeium
- Preferred regimen: Vancomycin 15 mg/kg q12h (trough levels 15-20 mcg/ml)
- Alternative regimen: Linezolid 600 mg IV q12h
- Note: No clinical studies available for Linezolid. Recommendation based on in vitro activity.
- 3.2 Chryseobacterium (Flavobacterium) spp.
- Preferred regimen: Levofloxacin 750 mg IV q24h
- Alternative regimen: Trimethoprim-Sulfamethoxazole 3–5 mg/kg PO/IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h
- 3.3 Ochrobacterium anthropi
- Preferred regimen: Trimethoprim-Sulfamethoxazole 3–5 mg/kg PO/IV q8h OR Ciprofloxacin 400 mg IV q8-12h
- Alternative regimen: (Ertapenem 1 g IV/IM q24h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h) AND Gentamicin 1 mg/kg IV q8h
- 3.4 Malassezia furfur
- Preferred regimen: Amphotericin B, Liposomal 3-5 mg/kg IV q24h
- Alternative regimen: Voriconazole 6 mg/kg IV q12h for first 24h THEN 4 mg/kg IV q12h
References
- ↑ 1.0 1.1 Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP; et al. (2009). "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America". Clin Infect Dis. 49 (1): 1–45. doi:10.1086/599376. PMC 4039170. PMID 19489710.