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. Certain conditions like nodular lymphagitis that is complicated by abscess and lymphedema with significant lymphatic obstruction may require surgical intervention.

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 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 ▸ 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 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 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 (max:40 mg/kg/day) 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 ▸ 25-50 mg/kg PO q8h plus Minocycline 2 mg/kg PO q12h OR ▸ Linezolid 10 mg/kg PO q8h For Animal Bites Preferred Regimen ▸ 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 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 or Minocycline 100 mg PO q12h OR ▸ TMP-SMZ 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h Children age >28 days ▸ Nafcillin 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-SMZ 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h

Methicillin-Resistant Staphylococcus Aureus (MRSA) Preferred Regimen Adult ▸ 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 or Minocycline 100 mg PO q12h OR ▸ TMP-SMZ 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-SMZ 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h

Pasteurella Preferred Regimen Adult ▸ 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' Adult ▸ 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 OR ▸ TMP-SMX 1 double strength tablet (sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h or 8-20 mg/kg IV divided q6-12h 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 Alternative Regimen ▸ Terbinafine 500 mg PO q12h OR ▸ Saturated solution of potassium iodide initiated at a dosage of 5-50 drops q8h OR ▸ Fluconazole 400-800 mg/day PO

Sporothrix Schenckii Preferred Regimen ▸ Itraconazole 200 mg PO q12h Alternative Regimen ▸ Terbinafine 500 mg PO q12h OR ▸ Saturated solution of potassium iodide initiated at a dosage of 5-50 drops q8h OR ▸ Fluconazole 400-800 mg/day PO

Brugia Malayi ▸ Diethylcarbamazine 6 mg/kg/day PO

Wuchereria Bancrofti ▸ Diethylcarbamazine 6 mg/kg/day PO

Other Therapies

• Analgesics and anti inflammatory medications can be used to control pain and inflammation.
• Hot, moist compresses can also be used to reduce pain and inflammation.

References