Septic Thrombophlebitis


Article Author:
Abdul Waheed
Lisa Foris


Article Editor:
Kevin King


Editors In Chief:
Michelle Miranda


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
6/6/2019 5:35:44 PM

Introduction

Suppurative (septic) thrombophlebitis (ST) describes thrombosis in a vein that occurs in the setting of inflammation and infection. This condition is characterized by the presence of a thrombus (with or without pus) that is associated with inflammation and pus formation (suppuration) both in the venous wall and surrounding the vessel. Although this process can occur in both superficial and deep vessels throughout the body, it is seen most commonly in venous structures (e.g. peripheral veins, pelvic veins, superior vena cava, internal jugular vein, portal veins or dural sinuses).[1][2][3]

Etiology

Although it can occur spontaneously, the majority of cases of peripheral ST result from breaks in the skin. Most often, peripheral, inferior vena cava or superior vena cava ST occurs as a consequence of an indwelling catheter (e.g. intravenous catheter (IVC) or peripherally inserted central venous catheter (PICC)), but it can also result from less invasive procedures such as venipuncture done for phlebotomy, or intravenous injection.  Additionally, phlebitis can occur without an underlying infection; simply as a result of catheter-related mechanical or chemical irritation (though infection should always be considered).[4][5][6]

Deep, non-catheter associated (e.g. pelvic, ovarian, pylephlebitis) ST may result from diverticulitis, endometritis, pelvic inflammatory disease, intra-abdominal infections, abdominal surgery, childbirth or septic abortion.

Lemierre syndrome (thrombophlebitis of the internal jugular vein) is most often caused by pharyngitis but may occur secondary to a dental infection as well.  

Dural vein ST may result from an ear, nose or throat infection (e.g. oropharyngeal infection, mastoiditis, otitis media, meningitis).  

All forms of ST can occur as a result of a hypercoagulable state.

Epidemiology

Individuals at the extremes of age (e.g. neonates and the elderly) appear to be the most vulnerable to ST - likely attributable to undeveloped host defenses in neonates, and a decline in immunologic function as well as additional comorbid disease in the elderly. [7][8][9]

The current incidence of catheter-associated (peripheral) ST is estimated at 0.5 cases of bloodstream infections per 1000 days of a peripherally inserted intravenous device. For non-tunneled, non-medicated, central venous catheters, the incidence is estimated at 2.7 per 1000 intravenous device days. Approximately 4.2% of burn patients experience peripheral ST.

Deep (non-catheter associated) ST is seen much less common; the exact incidence therefore not yet described. In the case of pelvic ST (seen most frequently in women of child-bearing age), it has been found to occur in 1 out of every 3000 deliveries, with the incidence being 10-fold greater with cesarean sections than with vaginal deliveries.  

Lemierre syndrome is also rare (an estimated 0.8 cases per 1 million per year in Europe) and often missed.  It occurs most commonly in healthy, young adults around the age of 20. 

Dural sinus ST is the rarest form of ST.

Pathophysiology

Though not all cases of catheter-associated sepsis result in ST, most cases of ST occur as a result of IVC or PICC line infection.

The incidence of ST in peripheral veins is highest in patients that have risk factors such as burns, steroid use or injection drug use. Burn patients are especially at risk due to impaired local host defenses as a result of lost skin integrity, a large number of organisms on the skin, hyperalimentation (e.g. total parenteral nutrition) and use of broad-spectrum antibiotics.

Lemierre's syndrome, which refers to thrombophlebitis of the internal jugular vein, occurs most commonly as a result of bacterial pharyngitis (e.g. pharyngitis that progresses to the formation of a peritonsillar abscess, which then ruptures and spreads to surrounding tissues and venous structures).

Infection in any part of the middle third of the face (e.g. nose, periorbital regions, tonsils, soft palate) poses the greatest risk of dural venous/sinus ST as these structures drain directly into the cavernous sinus (e.g. through ophthalmic veins, facial veins, and the pterygoid plexus). Additionally, meningitis and sinusitis have also been reported to be associated with dural sinus ST (e.g. through the direct spread of infection).

Pylephlebitis, which is ST of the portal vein, is a (rare) complication encountered with diverticulitis, but may also be caused by an intra-abdominal infection (e.g. structures draining into the portal vein).

Pelvic and ovarian vein ST occurs most commonly in the setting childbirth (within the first three weeks post-partum) due to local spread of a uterine infection (e.g. endometriosis) if present. The hypercoagulable state that occurs in the setting of pregnancy contributes to thrombus formation, and damage to iliofemoral vessels during childbirth further promotes this process.

The most common cause of ST is Staphylococcus aureus. Other commonly encountered microorganisms include streptococci and Enterobacteriaceae.  Burn patients may present with a polymicrobial infection.

History and Physical

Patients with ST typically present acutely with a fever along with erythema, tenderness and purulent drainage at the site of the involved vessel. Some patients may have associated respiratory distress (e.g. septic emboli to the lungs are common - may result in infiltrates, lung abscesses, pneumonia or empyema), and in the case of jugular vein ST, may also complain of localized throat or neck pain. Additionally, ulceration, a pseudomembrane or erythema may be visualized in the oropharynx of a patient with jugular vein ST. There may also be tenderness, swelling, or induration over the jugular vein, along with the sternocleidomastoid muscle, or over the angle of the jaw. 

Septic emboli may additionally travel to joints or bones resulting in septic arthritis or osteomyelitis - in which case the patient may complain of joint pains or body aches (e.g. in addition to fever, malaise, and night sweats).

Evaluation

There should be high clinical suspicion for ST in patients with bacteremia that persists for over 72 hours, despite the appropriate antibiotic therapy (especially if there is an IVC or PICC in place).  [10][11]

The best available test remains a contrast-enhanced computed tomography (CT) scan - this will allow for evaluation of any filling defects within a vessel that may potentially contain a clot and may additionally demonstrate any surrounding inflammation. Diagnosis is then made based on this radiographic evidence of thrombosis, taken together with results from blood cultures or cultures of purulent material obtained from a suspected site (e.g. tip culture in the case of catheter-associated thrombophlebitis, or Gram stain and culture of purulent material from a soft-tissue site). Tip cultures from both peripheral and central sites should be sent for comparison if available. It is important to note that a catheter should not be removed if there is a suspicion that the thrombus may be attached.

If CT scanning is unavailable, magnetic resonance imaging (MRI) may also be used for diagnosis of most cases of ST. In fact, MRI combined with MR venography is the most sensitive, non-invasive test for evaluating the dural sinuses.

Ultrasound may be useful in some cases of ST (e.g. if there is an abscess present very close to the involved vessel), and can also be diagnostic if a thrombus is revealed in the setting of a positive blood culture. In the cases of pelvic or dural vein thrombophlebitis, however, ultrasound will not provide an adequate study (due to poor penetration). 

Additional laboratory studies may include a complete blood count (to show leukocytosis), blood chemistries (may reveal acidosis or electrolyte imbalances), hepatic enzymes and liver function tests (if there is a suspicion of pylephlebitis), and International normalized ratio/prothrombin time (to assess whether anticoagulation is warranted).

Treatment / Management

The treatment of ST depends on the source of infection, the organisms involved, the structures being affected, and the individual patient's physiology. The main goals of treatment include removal of the source of infection (e.g. IVC or PICC), intravenous antibiotic administration (starting with empiric therapy and then adjusting according to culture and susceptibility results), and evaluation of surgical intervention (e.g. in the case of ongoing sepsis regardless of antimicrobial therapy) and/or anticoagulation.[12][13]

Consultations

  • Vascular surgeon because in some cases excision of the vein may be required to remove the source of infection.
  • Interventional radiology
  • Infectious disease

Enhancing Healthcare Team Outcomes

ST is not an uncommon diagnosis in hospitals. Because the condition can occur in any vein, the condition is best managed by a multidisciplinary team that includes a surgeon, an interventional radiologist and an infectious disease specialist. Nurses are often the first professionals to note the condition because the condition is often linked to peripheral vein cannulation. Once the condition is diagnosed, immediate treatment is necessary to prevent metastatic foci of infection in the systemic circulation. Mortality rates of 3-30% have been reported depending on the location of the vein and extent of infection. Infections associated with candida have the highest mortality. When the dural sinuses are involved, the mortality can exceed 70%. Today, with better imaging and improved diagnosis, the mortality rates have dropped, but any delay in treatment is associated with high morbidity and mortality. Once discharged, patients often need follow up to ensure that they have not developed endocarditis or a recurrent infection. To lessen the mortality, peripheral vein cannulation should be preferred over central vein cannulation.[14][8] (Level V)

 

 

 

 

 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Septic Thrombophlebitis - Questions

Take a quiz of the questions on this article.

Take Quiz
A patient had a difficult delivery with a traumatic episiotomy. Which of the following is most suggestive of septic pelvic thrombophlebitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is a sign of septic pelvic thrombophlebitis in a 34-year-old after a difficult delivery with a traumatic episiotomy?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the term for a vein with an infected blood clot?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 59-year-old woman with stage III breast cancer was started on chemotherapy following catheter placement in the left subclavian vein. Two months into treatment she presents with acute fever, chills, and numerous painful, swollen, erythematous lesions in both legs and arms. Following removal of her catheter, she is started on intravenous broad-spectrum antibiotics and blood cultures are sent for analysis. Doppler studies of all limbs did not show any obstruction to blood flow. Despite antibiotic treatment, fever persisted and more painful lesions developed on her limbs, in addition to some evolving into abscesses. All cultures including blood and purulent material from abscesses were negative showing no growth. Chest x-ray revealed multiple, round, irregular, non-cavitating opacities distributed bilaterally throughout the lungs. A transthoracic echo performed a few days later demonstrated a hyperdense structure in the superior vena cava extending 45x10x15 mm. What is the next step in treating this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Septic Thrombophlebitis - References

References

Losno RA,Vidal-Sicart S,Grau JM, Multiple pyomyositis secondary to septic thrombophlebitis. Medicina clinica. 2018 Oct 16     [PubMed]
Paker M,Cohen JT,Moed N,Shleizerman L,Masalha M,Ashkenazi D,Mazzawi S, Facial vein thrombophlebitis: A case report and literature review. International journal of pediatric otorhinolaryngology. 2018 Oct     [PubMed]
Nemakayala DR,P Rai M,Kavuturu S,Rayamajhi S, Atypical Presentation of Lemierre's Syndrome Causing Septic Shock and Acute Respiratory Distress Syndrome. Case reports in infectious diseases. 2018     [PubMed]
Alabraba E,Manu N,Fairclough G,Sutton R, Acute parotitis due to MRSA causing Lemierre's syndrome. Oxford medical case reports. 2018 May     [PubMed]
Ho VT,Rothenberg KA,McFarland G,Tran K,Aalami OO, Septic Pulmonary Emboli From Peripheral Suppurative Thrombophlebitis: A Case Report and Literature Review. Vascular and endovascular surgery. 2018 Jan 1     [PubMed]
De Smet K,Claus PE,Alliet G,Simpelaere A,Desmet G, Lemierre's syndrome: a case study with a short review of literature. Acta clinica Belgica. 2018 May 21     [PubMed]
San-Juan R,Viedma E,Chaves F,Lalueza A,Fortún J,Loza E,Pujol M,Ardanuy C,Morales I,de Cueto M,Resino-Foz E,Morales-Cartagena A,Rico A,Romero MP,Orellana MÁ,López-Medrano F,Fernández-Ruiz M,Aguado JM, High MICs for Vancomycin and Daptomycin and Complicated Catheter-Related Bloodstream Infections with Methicillin-Sensitive Staphylococcus aureus. Emerging infectious diseases. 2016 Jun     [PubMed]
Kim M,Kwon H,Hong SK,Han Y,Park H,Choi JY,Kwon TW,Cho YP, Surgical treatment of central venous catheter related septic deep venous thrombosis. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2015 Jun     [PubMed]
Nasr DM,Brinjikji W,Cloft HJ,Saposnik G,Rabinstein AA, Mortality in cerebral venous thrombosis: results from the national inpatient sample database. Cerebrovascular diseases (Basel, Switzerland). 2013     [PubMed]
Rebelo J,Nayan S,Choong K,Fulford M,Chan A,Sommer DD, To anticoagulate? Controversy in the management of thrombotic complications of head     [PubMed]
Hagan IG,Burney K, Radiology of recreational drug abuse. Radiographics : a review publication of the Radiological Society of North America, Inc. 2007 Jul-Aug     [PubMed]
Mimoz O,Rayeh F,Debaene B, [Catheter-related infection in intensive care. Physiopathology, diagnosis, treatment and prevention]. Annales francaises d'anesthesie et de reanimation. 2001 Jun     [PubMed]
Noël-Savina E,Paleiron N,Le Gal G,Descourt R, [Septic pulmonary embolism after removal of a venous access device for septic thrombophlebitis]. Journal des maladies vasculaires. 2012 Jun     [PubMed]
Cupit-Link MC,Nageswara Rao A,Warad DM,Rodriguez V, Lemierre Syndrome: A Retrospective Study of the Role of Anticoagulation and Thrombosis Outcomes. Acta haematologica. 2017     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Maternal Newborn RN. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Maternal Newborn RN, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Maternal Newborn RN, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Maternal Newborn RN. When it is time for the Nurse-Maternal Newborn RN board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Maternal Newborn RN.