Treatment plan for Superficial Thrombophlebitis

1.

Elsevier ClinicalKey Derived Clinical Overview

• Superficial suppurative thrombophlebitis is associated with an intravenous catheter or multiple puncture sites secondary to IV drug abuse and is located primarily in the upper extremity. • Clinical presentation is similar to that of nonsuppurative SVT but with associated fever, leukocytosis, and/or septicemia. • Most cases of intravenous catheter sepsis are not complicated by suppurative thrombophlebitis; local IV catheter site infections occur in about 7% of cases and septicemia is found in only 1 of every 400 IV catheterizations. • The incidence of peripheral vein suppurative thrombophlebitis is highest in patients with specific risk factors such as burns, steroids, and IV drug abuse. • Treatment consists of antibiotics with adequate coverage of gram-negative rods andStaphylococcus aureus,including MRSA. Initial empirical treatment is with IV vancomycin 1 g q12hplusceftriaxone 1 g IV q24h. Alternative regimen consists of daptomycin 6 mg/kg IV q12hplusceftriaxone 1 g IV q24h.

• Treatment guidelines for SVT are not well established because of the lack of controlled clinical trials. In general, the primary goal of management should be to prevent thrombus extension and the risk of venous thromboembolism. All other therapy is directed at patient comfort with analgesics and NSAIDs (in patients not receiving anticoagulants). • In patients with migratory SVT (Fig. E2), recurrent SVT, or SVT without varicose veins, the underlying condition should be investigated, and treatment directed accordingly. • The most common cause of upper-extremity SVT is an intravenous catheter. Treatment starts with removal of the cannula and application of warm compresses. The resultant lump may persist for months. No anticoagulant therapy is required. • In patients with lower-extremity SVT in a varicose vein branch, control of pain with analgesics and the use of gradient compression stockings are usually sufficient. Patients are encouraged to continue their usual daily activities. • Many investigators favor systemic anticoagulation when there is superficial thrombosis of 5 cm or more in length, the thrombus is within 1 cm of the saphenous junctions, or more than 5 cm of the saphenous trunk is involved, as shown by duplex ultrasonography. Anticoagulation is also reasonable for patients with SVT and cancer or previous DVT. • The American College of Chest Physicians guidelines recommend anticoagulation for 45 days over no anticoagulation in patients with lower-extremity SVT within 1 cm of the saphenofemoral or saphenopopliteal junction. • In the case of patients with varicose veins secondary to saphenous vein reflux, a catheter vein ablation procedure should be performed only after the acute SVT episode is over in order to avoid the thromboembolic complications induced by such procedures. FIG. E2Migrating superficial thrombophlebitis.From Micheletti RG et al:Andrews’ diseases of the skin, clinical atlas,ed 2, Philadelphia, 2023, Elsevier.

• Warm, moist compresses • Do not restrict activity. Immediate mobilization with walking exercises

2.

Weitz, Jeffrey I., Eikelboom, John W. (2024). In Goldman-Cecil Medicine (pp. 482). DOI: 10.1016/B978-0-323-93038-3.00068-X

Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), moderate or full doses of LMWH, fondaparinux, or rivaroxaban is approximately 70% more effective than placebo for treating superficial vein thrombosis. LMWH relieves symptoms more quickly and prevents thrombotic extension more effectively than do NSAIDs. Fondaparinux, 2.5mg/day for 45 days, reduces the risk of DVT or pulmonary embolism from approximately 1.3 to 0.2% without notable adverse effects. A 45-day course of rivaroxaban (10mg once daily) is as effective and safe as fondaparinux.Thus, it is reasonable to use these moderate doses of rivaroxaban, fondaparinux, or LMWH to treat symptomatic superficial vein thrombosis, particularly in patients with severe symptoms, proximal saphenous vein thrombosis, recurrent disease, or underlying cancer or thrombophilia. For less severe cases, topical or systemic NSAIDs can be prescribed. For treatment of varicose veins, laser and surgical treatments appear to be superior to liquid or foam sclerotherapy.

3.

Goldhaber, Samuel Z., Piazza, Gregory (2022). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (pp. 1635). DOI: 10.1016/B978-0-323-72219-3.00087-6

Short-term use of fondaparinux (2.5 mg once daily for 45 days) is the best validated anticoagulation strategy.In a randomized, open-label, noninferiority study of fondaparinux 2.5 mg daily versus rivaroxaban 10 mg daily for patients with superficial thrombophlebitis, rivaroxaban was found to be noninferior to fondaparinux and was not associated with more major bleeding.

4.

Elsevier ClinicalKey Clinical Overview

Treatment Superficial vein thrombophlebitis Involves superficial venous system and is associated with a low incidence of proximal deep vein thrombosis and pulmonary embolism Consider anticoagulation with prophylactic doses of low-molecular-weight heparin or fondaparinux for the following situations: Superficial vein thrombosis greater than 5 cm in length Severe symptoms Involvement of greater saphenous vein History of deep vein thrombosis or superficial vein thrombosis Active cancer Recent surgery Thrombophilia Genetic defects that predispose to venous thromboembolism are found in up to around 10% of the US general population Consider discussion with thrombophilia expert in patients with the following: Recurrent disease First idiopathic deep vein thrombosis when younger than 50 years Family history Massive thrombus Unusual site

5.

Di Nisio M, Middeldorp S. Jama. 2014;311(7):729-30. doi:10.1001/jama.2014.520.

Publish date: February 3, 2014.

CLINICAL QUESTION: What treatments for lower extremity superficial thrombophlebitis are associated with lower rates of venous thromboembolic events (VTE), major bleeding, and superficial venous thrombosis extension? BOTTOM LINE: Fondaparinux (2.5 mg) subcutaneously once daily for 45 days is associated with fewer symptomatic VTEs and lower rates of superficial venous thrombosis extension and recurrence with no increases in major bleeding compared with placebo. Low-molecular-weight heparin and nonsteroidal anti-inflammatory drugs are associated with lower rates of superficial thrombophlebitis extension or recurrence, but data regarding symptomatic VTEs are inconclusive.