Suppurative thrombophlebitis medical therapy
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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.