Lymphangitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Overview

Lymphangitis most often is an acute complication following an extension from the skin infection with the potential of a systemic spread. It has to be promptly treated with appropriate antibiotics along with analgesics, anti inflammatory medications, warm and moist compresses.

Principles of Therapy

• Prompt empirical antibiotic therapy that mostly covers beta-hemolytic streptococci should be started in order to prevent the rapid progression of lymphangitis.
• If the patients do not respond to the initial empirical antibiotic therapy or present with a systemic toxicity, then empiric coverage to methicillin-resistant staphylococcus aureus (MRSA) should be considered.
• Patients with mild to moderate disease can be managed in an outpatient setting and patients with severe disease should be managed in an inpatient setting.
• While treating the patients with antibiotics, the following should be considered
  • Carbapenems should not be used in patients with a history of hypersensitivity to beta-lactams.
  • TMP-SMX is not recommended for women in the third trimester of pregnancy and in children under 2 months of age.
  • Tetracyclines should not be used in children under 8 years of age.
• Besides antibiotics, analgesics, anti inflammatory medications, hot and moist compresses can be used to control pain and inflammation.
• Chronic sporotrichoid form of lymphangitis can be treated with chemotherapy.
• Recurrent lymphangitis can lead to chronic lymphedema, which can be treated with leg elevation, intermittent pneumatic compressions, manual massages, and multilayered bandage wrapping.
• Lymphatic filariasis can be treated with a one-day or a 12-day diethylcarbamazine regimen. The one-day regimen is as effective as the 12-day regimen.
• Findings of severe disease are:

• Hypotention
• C reactive protein over 13 mg/L
• CBC with marked left shift
• Elevated creatinine level
• 2 to 3 times the upper level of normal creatinine phosphokinase
• Low bicarbonate level

• Signs suggestive of severe infection:

• Cutaneous hemorrhage
• Disproportional pain
• Gas in the tissue
• Skin slaughin
• Violaceous bullae

Therapy Based on Clinical Form

Acute Lymphangitis

Empiric Therapy

▸ Click on the following categories to expand treatment regimens.

Mild - Moderate Acute Lymphangitis   ▸  Adults   ▸  Children age >28 days Severe Acute Lymphangitis   ▸  Adults   ▸  Children age >28 days

Mild - Moderate Acute Lymphangitis - Adults Preferred Regimen ▸ Penicillin V 500 mg PO q6h Alternative Regimen For Suspected Methicillin-Sensitive Staphylococcus Aureus (MSSA) ▸ Dicloxacillin 500 mg PO q6h OR ▸ Cephalexin 500 mg PO q6h For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 300-450 mg PO q8h OR ▸ TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h OR ▸ Doxycycline 100 mg PO q12h OR ▸ Minocycline 100 mg PO q12h OR ▸ Linezolid 600 mg PO q12h For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 300-450 mg PO q8h OR ▸ Amoxicillin 500 mg PO q8h PLUS TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h OR ▸ Amoxicillin 500 mg PO q8h PLUS Doxycycline 100 mg PO q12h OR ▸ Amoxicillin 500 mg PO q8h PLUS Minocycline 100 mg PO q12h OR ▸ Linezolid 600 mg PO q12h For Animal Bites ▸ Amoxicillin-clavulanate 875 mg PO q12h Mild - Moderate Acute Lymphangitis - Children Preferred Regimen ▸ Penicillin V 500 mg PO q6h Alternative Regimen For Suspected Methicillin-Sensitive Staphylococcus Aureus (MSSA) ▸ Dicloxacillin 25 mg/kg PO divided q6h OR ▸ Cephalexin 25 mg/kg PO divided q6h For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 10-13 mg/kg PO q6-8h OR ▸ TMP-SMX 8–12 mg/kg (based on trimethoprim component) PO q12h OR ▸ Doxycycline ≤45 kg: 2 mg/kg PO q12h; >45 kg: 100 mg PO q12h ¶ OR ▸ Minocycline 2 mg/kg PO q12h ¶ OR ▸ Linezolid 10 mg/kg PO q8h ¶ Not recommended for children < 8 years of age For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 10-13 mg/kg PO q6-8h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS TMP-SMX 8–12 mg/kg (based on trimethoprim component) PO q12h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS Doxycycline ≤45 kg: 2 mg/kg PO q12h; >45 kg: 100 mg PO q12h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS Minocycline 2 mg/kg PO q12h OR ▸ Linezolid 10 mg/kg PO q8h For Animal Bites ▸ Amoxicillin-clavulanate 20 mg/kg PO divided q12h Severe Acute Lymphangitis - Adults Preferred Regimen ▸ Penicillin G 2-4 MU IV q4-6h Alternative Regimen For Suspected Methicillin-Sensitive Staphylococcus Aureus (MSSA) ▸ Nafcillin 1-2 g IV q4h OR ▸ Oxacillin 1-2 g IV q4h OR ▸ Cefazolin 1 g IV q8h OR ▸ Clindamycin 300-450 mg PO q8h OR ▸ Erythromycin 500 mg PO q6h For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Vancomycin 15-20 mg/kg IV q8-12h OR ▸ Linezolid 600 mg IV q12h OR ▸ Daptomycin 4mg/kg IV q24h OR ▸ Clindamycin 600 mg IV/PO q8h OR ▸ Telavancin 10 mg/kg IV q12h For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 300-450 mg PO q8h OR ▸ Amoxicillin 500 mg PO q8h PLUS TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h OR ▸ Amoxicillin 500 mg PO q8h PLUS Doxycycline 100 mg PO q12h OR ▸ Amoxicillin 500 mg PO q8h PLUS Minocycline 100 mg PO q12h OR ▸ Linezolid 600 mg PO q12h For Animal Bites ▸ Ampicillin sulbactam 3 g IV q6h Severe Acute Lymphangitis - Children Preferred Regimen ▸ Penicillin G 2-4 MU IV q4-6h Alternative Regimen For Suspected Methicillin-Sensitive Staphylococcus Aureus (MSSA) ▸ Nafcillin 100–150 mg/kg IV q6h OR ▸ Oxacillin 100–150 mg/kg IV q6h OR ▸ Cefazolin 50 mg/kg IV q8h OR ▸ Clindamycin 10-13 mg/kg IV q6-8h OR ▸ Erythromycin 10 mg/kg PO q6h For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Vancomycin 15 mg/kg IV q6h OR ▸ Linezolid 10 mg/kg IV/PO q8h OR ▸ Daptomycin 5-9 mg/kg IV q24h OR ▸ Clindamycin 10-13 mg/kg IV/PO q6-8h For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Clindamycin 10-13 mg/kg PO q6-8h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS TMP-SMX 8–12 mg/kg (based on trimethoprim component) PO q12h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS Doxycycline ≤45 kg: 2 mg/kg PO q12h; >45 kg: 100 mg PO q12h OR ▸ Amoxicillin 25-50 mg/kg PO q8h PLUS Minocycline 2 mg/kg PO q12h OR ▸ Linezolid 10 mg/kg PO q8h For Animal Bites ▸ Ampicillin sulbactam 50 mg/kg IV q6h

Pathogen Based Therapy

▸ Click on the following categories to expand treatment regimens.>

Bacteria   ▸  Streptococcus Pyogenes   ▸  Methicillin Sensitive Staphylococcus Aureus   ▸  Methicillin Resistant Staphylococcus Aureus   ▸  Pasteurella Multocida

Streptococcus Pyogenes Preferred Regimen ▸ Penicillin V 500 mg PO q6h OR ▸ Penicillin G 2-4 MU IV q4-6h Alternative Regimen For Life-Threatening Penicillin Allergies Adults ▸ Clindamycin 300-450 mg PO q8h OR ▸ Vancomycin 15-20 mg/kg IV q8-12h Children age >28 days ▸ Clindamycin 10-13 mg/kg IV q6-8h OR ▸ Vancomycin 15 mg/kg IV q6h Methicillin-Sensitive Staphylococcus Aureus (MSSA) Preferred Regimen Adults ▸ Nafcillin 1-2 g IV q4h OR ▸ Oxacillin 1-2 g IV q4h OR ▸ Cefazolin 1 g IV q8h OR ▸ Clindamycin 300-450 mg PO q8h or 600 mg/kg IV q8h OR ▸ Erythromycin 500 mg PO q6h OR ▸ Dicloxacillin 500 mg PO q6h OR ▸ Cephalexin 500 mg PO q6h OR ▸ Doxycycline 100 mg PO q12h OR ▸ Minocycline 100 mg PO q12h OR ▸ TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h Children age >28 days ▸ Nafcillin 100–150 mg/kg IV q6h OR ▸ Oxacillin 100–150 mg/kg IV q6h OR ▸ Cefazolin 50 mg/kg IV q8h OR ▸ Clindamycin 10–20 mg/kg PO q8h or 25–40 mg/kg IV q8h OR ▸ Erythromycin 10 mg/kg PO q6h OR ▸ Dicloxacillin 25 mg/kg PO q6h OR ▸ Cephalexin 25 mg/kg PO q6h OR ▸ TMP-SMX 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h Methicillin-Resistant Staphylococcus Aureus (MRSA) Preferred Regimen Adults ▸ Vancomycin 30 mg/kg IV q12h OR ▸ Linezolid 600 mg IV/PO q12h OR ▸ Clindamycin 300-450 mg PO q8h or 600 mg/kg IV q8h OR ▸ Daptomycin 4mg/kg IV q24h OR ▸ Doxycycline 100 mg PO q12h OR ▸ Minocycline 100 mg PO q12h OR ▸ TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h Children age >28 days ▸ Vancomycin 40 mg/kg IV q6h OR ▸ Linezolid 10 mg/kg IV/PO q12h OR ▸ Clindamycin 10–20 mg/kg PO q8h or 25–40 mg/kg IV q8h OR ▸ TMP-SMX 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h Pasteurella Multocida Preferred Regimen Adults ▸ Amoxicillin-clavulanate 875 mg PO q12h OR ▸ Ampicillin sulbactam 3 g IV q6h Children age >28 days ▸ Amoxicillin-clavulanate 20 mg/kg PO divided q12h OR ▸ Ampicillin sulbactam 50 mg/kg IV q6h Alternative Regimen Adults ▸ Ertapenem 1 g IM/IV q24h OR ▸ Cefoxitin 1 g IV q4h or 2 g IV q8h OR ▸ Meropenem 1 g IV q8h OR ▸ Imipenem cilastatin 500 mg IV q6h OR ▸ Doxycycline 100 mg PO/IV q12h PLUS Clindamycin 450 mg PO or 600 mg IV q8h OR ▸ TMP-SMX 1 double strength tablet (sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h or 8-20 mg/kg IV divided q6-12h PLUS Clindamycin 450 mg PO or 600 mg IV q8h OR ▸ Moxifloxacin 400 mg PO/IV q24h PLUS Clindamycin 450 mg PO or 600 mg IV q8h Children age >28 days ▸ Ertapenem 15 mg/kg IM/IV q12h OR ▸ Cefoxitin 160 mg/kg IV divided q4-6h OR ▸ Meropenem 20 mg/kg IV q8h OR ▸ Imipenem cilastatin 25 mg/kg IV q6h OR ▸ TMP-SMX 4-5 mg/kg (trimethoprim component) PO/IV q12h PLUS ▸ Clindamycin 10 mg/kg PO/IV q8h

Chronic Lymphangitis

Pathogen Based Therapy

▸ Click on the following categories to expand treatment regimens.

Bacteria   ▸  Mycobacterium Marinum Fungi   ▸  Sporothrix Schenckii Parasites   ▸  Brugia Malayi   ▸  Wuchereria Bancrofti

Mycobacterium Marinum Preferred Regimen ▸ Clarithromycin 500 mg PO q12h PLUS Ethambutol 15 mg/kg PO q24h OR ▸ Rifampin 600 mg PO q24h

Sporothrix Schenckii Preferred Regimen ▸ Itraconazole 200 mg PO q24h Alternative Regimen† ▸ Itraconazole 200 mg PO q12h OR ▸ Terbinafine 500 mg PO q12h OR ▸ Saturated solution of potassium iodide 5-50 drops q8h OR ▸ Fluconazole¶ 400-800 mg/day PO ¶ Only administer if patient can't tolerate other antifungal agents † If there is no improvement after preferred treatment

Brugia Malayi Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO

Wuchereria Bancrofti Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO