Suppurative thrombophlebitis medical therapy

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.

• 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]

• 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

• 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

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