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],Faizan Sheraz, M.D. [3]

Overview

The mainstay of therapy in lymphangitis is antimicrobial therapy. Supportive therapy includes analgesics, anti-inflammatory agents, and warm compresses.

Medical Therapy Adapted from Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases.

• Prompt empirical antibiotic therapy that mostly covers beta-hemolytic streptococci should be started in order to prevent the rapid progression of lymphangitis.
• Staphylococcal infection should be suspected if prominent suppuration is observed at the primary site of infection.
• If the patient does not respond to the initial empirical antibiotic therapy, present with symptoms of systemic toxicity or if the prevalence of methicillin-resistant staphylococcus aureus (MRSA) infections is high in the community, empirical coverage 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.
• The chronic sporotrichoid form of lymphangitis can be treated with chemotherapy.
• When Mycobacterium marinum infection is suspected, confirmation should be assessed utilizing an acid-fast bacilli analysis and organism isolation.
• 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.

Laboratory Findings of Severe Disease Adapted from the 2005 IDSA Practice guidelines for the diagnosis and management of skin and soft-tissue infections.

• 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 and Symptoms Suggestive of Severe Infection Adapted from the 2005 IDSA Practice guidelines for the diagnosis and management of skin and soft-tissue infections.

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

Acute Lymphangitis

• Preferred regimen: Dicloxacillin
• Preferred regimen: Cephalexin 500 mg PO qid for 1 week

• 2. Patient with lymphangitis and if Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) suspected:

• Trimethoprim-sulfamethoxazole PO bid AND vancomycin 1 g IV every 12 hr

• 3.Patient with lymphangitis allergic to penicillin:

• Clindamycin 300 mg PO qid for 7 days OR Erythromycin 500 mg PO qid for 7 days OR Levofloxacin 500 mg PO daily OR Moxifloxacin 400 mg PO daily for 7 days.

Empiric Therapy Adapted from Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases.Adapted from Clin Infect Dis. 2005 Nov 15;41(10):1373-406. J Emerg Med. 2013 Jun;44(6):e397-412.Clin Infect Dis. 2011 Feb 1;52(3):e18-55.

▸ 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 (160/800 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 ▸ Doxycycline 100 mg PO q12h OR ▸ 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 < 12 years-old 25-50 mg/kg/day PO divided q6-8h (maximum 3 g/day), > 12 years-old 250-500 mg PO q6-8h 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 IV q6-8h OR ▸ Amoxicillin 500 mg PO q8h PLUS ▸ 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 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 For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA) ▸ Vancomycin 15-20 mg/kg IV q8-12h OR ▸ Linezolid 600 mg IV/PO 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 600 mg IV/PO q8h OR ▸ Linezolid 600 mg IV/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 IV/PO q6-8h OR ▸Linezolid 10 mg/kg IV/PO q8h For Animal Bites ▸ Ampicillin sulbactam 50 mg/kg IV q6h

Pathogen Based Therapy Adapted from Clin Infect Dis. 2005 Nov 15;41(10):1373-406. J Emerg Med. 2013 Jun;44(6):e397-412.Clin Infect Dis. 2011 Feb 1;52(3):e18-55.

▸ 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 (800/160 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 OR Ertapenem 1 g IM/IV q24h Alternative Regimen Adults ▸ 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 (800/160 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 PLUS ▸ Ethambutol 15 mg/kg PO q24h Adapted from Eur J Clin Microbiol Infect Dis. 2006 Oct;25(10):609-13. Am J Respir Crit Care Med. 2007 Feb 15;175(4):367-416.

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 † If there is no improvement after preferred treatment ¶ Only administer if patient can't tolerate other antifungal agents Adapted from Clin Infect Dis. 2007 Nov 15;45(10):1255-65. Epub 2007 Oct 8

Brugia Malayi Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO Adapted from Parasites - Lymphatic Filariasis CDC page.

Wuchereria Bancrofti Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO Adapted from Parasites - Lymphatic Filariasis CDC page.