Septic Superficial Thrombophlebitis: a Major Threat from a Minor Lesion

Septic superficial thrombophlebitis: a major threat from a minor lesion

Bernard J. Mezon, md; Andrus J. Voitk, md

Sites of insertion of peripheral intra¬ mon, its incidence correlates imper- fossa. CVP monitoring was discontinued venous catheters remain an important fectly with that of local infection with after 2 days and the established line used to administer fluids but often overlooked source of or without septicemia.3,4 Not only is no intravenous and and the obtained from culture of mate¬ medication. When drainage failed to oc¬ hospital-acquired septicemia growth cur the anastomosis be¬ most source of rial from at through biliary important staphylococcal many catheter tips sites cause of an de¬ thrombo¬ with unrecognized anomaly, septicemia. Septic superficial phlebitis, but culture of material scribed elsewhere,10 an end-to-side chole- phlebitis is characterized by severe from the tip at many clinically normal dochoenterostomy was fashioned 4 days local pain and is readily evident intravenous sites yields pathogenic or¬ after the first operation. The night after clinically. Care of the intravenous line ganisms, thus proving these sites to be the second operation the patient com¬ can prevent this complication. To be the source of septicemia. Staphylococcus plained of pain in his left arm and the it must be aureus is the cultured in more next morning his temperature was 39.2°C. diagnosed, suspected. pathogen Acute and Treatment consists of removal of the than 50% of instances; the others are superficial thrombophlebitis intravenous line and administration cellulitis surrounding the left cephalic mostly gram-negative bacilli,3'4 among vein were noted. The intravenous catheter of heparin and antibiotics effective which Klebsiella and Aerobacter pre¬ was removed and cultures made, blood against penicillinase-producing organ¬ dominate. This is in contrast to sepsis samples were taken for culture, and isms. Occasionally the vein must be associated with intravenous hyperali- therapy was begun with cloxacillin, 1 g IV ligated or, preferably, removed. mentation, in which Candida is the q4h, clindamycin, 300 mg IV q6h, and usual pathogen and gram-negative gentamicin, 40 mg IV q4h. Within 24 Le point d'insertion des catheters bacteria, often nonpathogenic species, hours the cellulitis subsided and the arm intraveineux demeure are was no longer painful. Blood and mate¬ peripheriques occasionally responsible.1,2 Staphy¬ rial from the catheter une source mais souvent lococcus is the causative tip grew penicillin- importante organism resistant S. aureus. and gen¬ oubliee de contractees a much more to Clindamycin septicemies often in septicemia due tamicin were stopped and cloxacillin was l'hopital, et la source la plus importante contaminated intravenous catheters than continued for 10 days. In 4 days' time he des septicemies a staphylocoques. La in septicemia due to other causes, the was afebrile and at the time of discharge thrombophlebite superficielle septique frequencies being 70% and 15 to 20%, the left arm and cephalic vein appeared est caracterisee par une douleur respectively, according to one group.3 normal. locale intense et elle est cliniquement When the intravenous line is being Comment: Pain associated with septic is so severe evidente. Des soins portes a la established, the risk of both thrombo¬ superficial thrombophlebitis tubulure intraveineuse and infection is increased that it may be a patient's sole complaint peut prevenir phlebitis by even after abdominal cette etre lack of immediately major complication qui, pour aseptic technique3,4 and undue surgery. In half the cases of septicemia diagnostiquee, doit etre suspectee. trauma to the vein;3 the type and size due to contamination of intravenous sites Le traitement consiste a retirer la of cannula6 and the material from in one study, local symptoms and signs tubulure intraveineuse et a administrer which the cannula is made are also im¬ were evident 1 to 2 days before the onset de I'heparine et des antibiotiques portant factors.7 After the catheter is of septicemia.4 The presence of intra- efficaces contre les microorganismes inserted, sepsis may occur because of venous-catheter-related thrombophlebitis in producteurs de penicillinase. A failure to anchor the catheter,45 careless undiagnosed sepsis warrants inclusion in the antibiotic of an effect¬ I'occasion on avoir a violation of the for administra¬ regimen agent peut ligaturer system ive organ¬ la de a I'enlever. tion of ade¬ against penicillinase-producing veine, ou, preference, medications5 and lack of isms. The response to appropriate anti¬ quate surveillance and maintenance.3,4 biotic therapy is usually rapid and uncom¬ Since the advent of intravenous hyper- The risk of septicemia increases the plicated. The gravity of this complication alimentation much attention has been longer the catheter is in place, but if of intravenous therapy is illustrated by the fatal outcome of focused on sepsis associated with this it is in place for less than 48 hours sep¬ potentially compli¬ used ticemia probably will not occur.3,4 Con¬ cated major surgery because of a "minor" technique,12 while the commonly deviation in technique. peripheral vein has been neglected as a taminated intravenous solutions occa¬ source of life-threatening sepsis. It is sionally may be the cause of sepsis,8 al¬ Case 2 estimated that 20% of all though in most instances the solution septicemias A 27-year-old man was admitted to hos¬ are to in¬ has been found to be sterile9 and poor related contamination of pital with blunt chest injury and an acute dwelling intravenous catheters.3 One technique instead was implicated. abdomen. Laparotomy revealed hemato¬ group found that in 43% of hospital- The following two case reports illus¬ mas but no free bleeding or visceral acquired septicemias the inoculation trate how serious this complication may damage. Bilateral hemothoraces were site was an indwelling peripheral venous be. treated with closed chest tube drainage. catheter,4 and another group estimated Postoperative respiratory failure was the rate of catheter-induced bacteremia Case treated in the intensive care unit with en- reports dotracheal intubation and a in their to be ventilator. A large hospital 200/yr.5 Case 1 CVP catheter inserted in the left ante¬ Although thrombophlebitis is com- cubital fossa failed to function; it was used A 39-year-old man underwent pancre*- for administration of intravenous fluids aticoduodenectomy for chronic pancrea¬ and medication. From the departments of surgery, University titis localized to the head of the Two later his rose to of Manitoba, Winnipeg, and Soldiers' Memorial pancreas* days temperature Hospital, Orillia, Ont. During the operation a central venous 39°C and he complained of pain in his catheter was threaded into left where was evident. The Reprint requests to: Dr. A. Voitk, 34 Market pressure (CVP) arm, phlebitis St., Orillia, ON L3V 3C9 the left cephalic vein from the antecubital fever was attributed to pulmonary infec- 1128 CMA JOURNAL/JUNE 19, 1976/VOL. 114 tion and diagnostic investigations were colonies (Fig. 1), and culture grew penicil¬ To prevent this complication, one instituted while antibiotics were withheld. lin-resistant Staphylococcus, should not give therapy intravenously This case illustrates the im¬ The next day the intravenous line in the Comment: when other routes are adequate; in¬ left arm was removed because of a leak; portance of the clinician's heeding symp¬ dwelling catheters should be reserved note was made again of phlebitis. On the toms and looking for thrombophlebitis and of his 4th postoperative day he had cellulitis when dealing with septicemia in for situations in which prolonged ther¬ night is our chills and rigor, his temperature rising a patient receiving intravenous therapy. apy anticipated. Both cases illus¬ to 40 °C. If thrombophlebitis is detected, immediate trated the need to remove long cannulas Blood samples were taken for culture inclusion in the antibiotic regimen of an when no longer required. Careful pre¬ and treatment begun with gentamicin, 150 agent effective against penicillinase-produ¬ paration of the site and atraumatic in¬ mg IV q8h, and methicillin, 2 g IV q6h, cing organisms is indicated while culture sertion are important when intravenous the latter being chosen because cultured reports are awaited. If appropriate therapy lines are established. The catheter tracheal aspirates had grown penicillin- is delayed the patient may fail to respond should be firmly anchored and viola- resistant S. aureus. A spiking fever, with to even excessively high doses of the ap¬ tions of the line should be minimal and between 38 and con¬ propriate antibiotic. The clot will extend temperatures 40°C, carried out under tinued and inflammation of the left ce¬ beyond clinically apparent confines and aseptic conditions. phalic vein persisted. Gentamicin therapy the infection may establish itself within Daily application of a topical antibiotic was stopped when blood cultures yielded the clot, where antibiotics cannot penetrate. to the site prevents sepsis11 but even penicillin-resistant Staphylococcus. His pul¬ Treatment at this stage requires surgical this method is not considered safe be¬ monary function had improved and the removal of the source of sepsis. The salu- yond 96 hours.12 Although central left cephalic vein was now thought to be tary effect of this approach is illustrated venous catheters for hyperalimentation the source of sepsis. He was transferred by the prompt response in this patient. have been successfully and routinely to a ward and methicillin was replaced maintained infection-free for 3 weeks with 3 g IV was cloxacillin, q4h; heparin Discussion or such results can be also given. Cellulitis of the arm abated more, expected and his temperature decreased; the cephalic Although septic superficial thrombo¬ only with painstaking attention to the vein remained tender, however, and the phlebitis has received some attention in site and line at all times.13 Unless one is temperature continued to spike up to 38 °C. the past, it continues to be overlooked. prepared to care for superficial intra¬ After 3 days of no further improvement treatment was venous lines in a similar manner, it is of the cannula and Thus, appropriate unduly (9 days after insertion in our second For the advisable to change sites every 48 7 after institution of intra¬ delayed patient. days specific same reason a review of hours. venous antibiotic therapy) the inflamed hospital septic vein was removed. His temperature was superficial thrombophlebitis could not When thrombophlebitis, infection or normal in the recovery room and remained be carried out because this diagnosis sepsis is evident, the intravenous cathe¬ so until discharge. He went home afebrile had not been recorded in any charts, ter should be removed and material at and pain-free, continuing to take cloxacil¬ although discussion with colleagues re¬ its tip cultured. Antibiotics effective lin orally for 1 month as prophylaxis vealed several such cases. Even when against penicillin-resistant Staphylococ¬ against bacterial endocarditis. the condition is diagnosed and treated, cus should be given to patients with Although clinically the phlebitis ex¬ it is too minor to while culture results are awaited. tended half the arm, at apparently thought sepsis only way up oper¬ with the If thrombosis is a concomitant ation the cephalic vein was found to con¬ record, compared primary feature, tain clot almost up to its junction with reason for hospitalization. Nevertheless, heparin therapy is also advisable. When the axillary vein. The clot contained many the complication is a potentially serious the infection is entrenched, as in the gram-positive cocci, both isolated and in one, as demonstrated by our two cases. second patient, antibiotic therapy may

FIG- 1.Left: thrombophlebitis and acute inflammatory reaction in left cephalic vein of patient 2 (Gram's stain; reduced by 20% from xlO). Right: small colony of Staphylococcus aureus in oil-immersion enlargement of area in box (reduced by 20% from xlOO). CMA JOURNAL/JUNE 19, 1976/VOL. 114 1129 Gynecol Obstet 135: 708, 1972 prove inadequate. Although Barza and 3. COLAPINTO ND, BEDARD P, GOLDMAN BS: Weinstein14 have shown that adequate Bloodstream infection associated with pro. longed intravenous therapy. Can I Surg 15: Canesterv concentrations of antibiotic can be 27, 1972 Antifungal and clotrimazole attained in clots in vivo, they acknowl- 4. BENTLEY DW, LEPPER MH: Septicemia re- trichomonacidal agent lated to indwelling venous catheter. JAMA edge that in vitro clots are not homo- 206: 1749, 1968 5. COLLINs RN, BRAUN PA, ZINNER SH, et al: PRESCRIBING INFORMATION geneous, as in the experimental situa- Risk of local and systemic infection with INDICATIONS Canesten Cream and Solution: Topical tion, and may not permit similar polyethylene intravenous catheters. N Engi I treatment of the following dermal infections tinea pedis, Med 279: 340, 1968 tinea cruris and tinea corporis due to T. rubrum, T. menta- concentrations of antibiotic. With 6. PETER G, LLOYD-STILL JD, LOVEJOY FH: grophytes and Epidermophyton floccosum; candidiasis due Local infection and bacteremia from scalp to C. albicans; tinea versicolor due to Malassezia furfur. extensive spread of thrombosis and vein needles and polyethylene catheters in Canesten Vaginal Tablets: Treatment of vaginal candidiasis children. I Pediatr 80: 78, 1972 and trichomoniasis. Canesten Vaginal Tablets may be used acute inflammatory reaction, blood sup- 7. WELCH GW, MCKELL DW, SILvERsraIN P, in both pregnant and non-pregnant women, as well as in ply to a long segment of clot may be et al: The role of catheter composition in women taking oral contraceptives. (See Precautions) the development of thrombophlebitis. Surg DOSAGE AND ADMINISTRATION Cream and Solution: virtually nonexistent; hence a nidus of Gynecol Obstet 138: 421, 1974 Thinly apply and gently massage sufficient cream or solu- infection could remain in spite of anti- 8. FELTS SK, SCHAFFNER W, MELLY MA, et al: tion into the affected and surrounding skin areas twice Sepsis caused by contaminated intravenous daily, in the morning and evening. biotic therapy. In such a situation fluids. Ann Intern Med 77: 881, 1972 For vulvitis. Canesten Cream should be applied to the vulva 9. DuMA RJ, WARNER JF, DALTON HP: Septi- and as far as the anal region. For balanitis and prevention of proximal ligation and division of the vaginal infection or reinfection by the partner. Canesten cemia from intravenous infusions. N Engi I Cream should be applied to the glans penis. vein must be undertaken. Although this Med 284: 257, 1971 Vaginal Tablets: One tablet a day for six consecutive days. 10. Vorrx AJ: Double barrelled common bile Using the applicator, insert one tablet deep intravaginally, may be enough to prevent continued duct: a threat to billary surgery. Am I preferably at bedtime. In order to avoid treatment during seeding of the organisms, it is difficult Surg (in press) menstruation, it is suggested that treatment be started at 11. NORDEN CW: Application of antibiotic oint- least 6 days prior to the anticipated menstrual period. to envisage amelioration of a situation ment to the site of venous catheterization: a controlled trial. I Inject DURATION OF TREATMENT Cream and Solution: The Dis 120: 611, duration of therapy varies and depends on the extent and such as in case 2 with any therapy short 1969 localization of the disease. Generally, clinical improvement of surgical removal of the clot and its 12. SMITs H, FREEDMAN LR: Prolonged venous with relief of pruritus usually occurs within the first week of catheterization as a cause of sepsis. N Engi treatment. Tinea infections require approximately 3-4 weeks nest of pathogenic bacteria. I Med 276: 1229, 1967 of therapy while in candidiasis, -2 weeks treatment is often 13. COPELAND EM, MACFAYDEN BV JR, MCGOWN adequate. If no clinical improvement is observed after 4 C, et al: The use of hyperallmentation in weeks, the diagnosis should be reviewed. References patients with potential sepsis. Surg Gynecol If a cure is not mycologically confirmed or in order that Obstet 139: 377, 1974 relapses may be prevented (particularly in mycoses of the 1. Cusiay CR, Qui P6: Fungal septicemia in 14. BARZA M, WEINsTEIN L: Penetration of foot), treatment should, as a rule, be continued for 2 weeks patients receiving parenteral hyperalimenta- antibiotics into fibrin loci in vivo. I. Com- after all clinical symptoms have disappeared. tion. N Engi I Med 285: 1221, 1971 parison of ampicillin penetration into fibrin Vaginal Tablets: The six-day therapy may be repeated if 2. FREEMAN JB, LaMista A, MACLEAN LD: In- clots, abscesses and "interstitial fluid". I necessary. travenous alimentation and septicemia. Surg Inject Dis 129: 59, 1974 SPECIAL REMARKS Cream and Solution: Added hygienic measures are of special importance in the management of the often refractory fungal diseases of the foot. To avoid trapped moisture, the feet - particularly between the toes - should be dried thoroughly after washing. Onychomycoses, owing to their location and physiological factors, generally respond poorly to topical antimycotic therapy alone due to poor penetration into horny substance. Treatment with Canesten may be considered in cases of CORRESPONDENCE As to the question of proof of the paronychia and as adjunctive therapy in onychomycoses following extraction or ablation of the nail. continued from page 1126 value of long-term psychotherapy, Vaginal Tablets: Added hygienic measures such as twice daily tub baths and avoidance of tight underclothing is there are, in fact, research studies that highly recommended. demonstrate its value,1 but the ques- In the case of clinically significant trichomonal infection. Shrink additional therapy with a systemic trichomonacidal agent tion is more complex than just effec- should be considered. Such therapy is essential for the To the editor: Dr. Elliott Emanuel's ar- treatment of vaginal infections which may also involve tiveness or ineffectiveness. One must Bartholins glands and the urethra. ticle "Shrink" (Can Med Assoc J 114: ask not only what kind of therapy for CONTRAINDICATIONS Except for possible hyper- sensitivity, Canesten Solution, Cream and Vaginal Tablets 604, 1976) contains so many useful what kind of patient but also what have no known contraindications. points eloquently stated that I feel it kind of therapist. I might ask Dr. PRECAUTIONS As with all topical agents, skin sensitiza- tion may result. Use of Canesten topical preparations should necessary to point out the areas in Emanuel how many "scientific" treat- be discontinued should such reactions occur, and appropriate therapy inCtituted. which his portrait of the psychiatrist ments in medicine could stand up to Canesten Solution and Cream are not for ophthalmic use. is distorted and one-sided. It is true the scrutiny of a controlled double- Canesten Vaginal Tablets are not for oral use. Use in Pregnancy: Although intravaginal application of that for a long time the value of short- blind study? Certainly antibiotic clotrimazole has shown negligible absorption from both normal and inflamed human vaginal mucosa, Canesten term intervention in psychiatry has therapy for bacterial infection, but Vaginal Tablets should not be used in the first trimester of been under-rated, although this is being preg nancy unless the physician considers it essential to the probably not many surgical techniques welfare of the patient. remedied - the body of literature that produce no universal results, yet The use of the supplied applicator may be undesirable in some pregnant patients, and digital insertion of the tablets on time-limited psychotherapy and have a reasonable likelihood of suc- is an alternative which should be considered. crisis intervention is growing rather cess based on lengthy clinical ex- SIDE EFFECTS Large scale clinical trials have shown that Canesten is very well tolerated after topical and vaginal large. But to discount entirely the perience. application. of psychotherapy as Cream and Solution: Erythema, stinging, blistering, peeling, value long-term JOEL PARis, MD edema, pruritus, urticaria, and general irritation of the skin "unproven" is to deny many patients have been reported infrequently. Institute of community and family psychiatry Vaginal Tablets: Skin rash, lower abdominal cramps, slight the only technique that will produce Jewish General Hospital urinary frequency, and burning or irritation in the sexual Montreal, PQ partner, have occurred rarely. In no case was it necessary a lasting result. Dr. Emanuel's descrip- to discontinue treatment with Canesten Vaginal Tablets. tion of long-term therapy as being AVAILABILITY Canesten Solution 1% ix supplied in 20 ml Reference plastic bottles, in carton. Each ml contains 10 mg of given only to an affluent and self- clotrimazole in a non-aqueous vehicle. 1. MELTZOFF J, KORNaEIcH M: Research in Canesten Cream 1% ix supplied in 20 g tubes, in carton. indulgent subgroup might have applied Psychotherapy, New York, Atherton Pr, 1970 Each g contains 10 mg of clotrimazole in vanishing cream before medicare was introduced, but base. Canesten Vaginal Tablets 1 00 mg are supplied in boxes since psychotherapy has been avail- containing one strip of six tablets with plastic applicator and able under medicare it has been pos- To the editor: I give long-term psy- patient leaflet of instructions. chotherapy to some patients and, of REFERENCES 1. Lohmeyer, H., Postgrad. Med. J., 50 sible to offer this kind of treatment to Suppl. 78, 1 974. / 2. Schnell, J.D., Ibid., p. 79. 3. Legal. course, I see patients who have re- H.P., Ibid., p.81 /4. Widholm, 0., Ibid., p.85. 5 Couch- people from all social classes and man, J.M. Ibid., p. 93. / 6. Higton, BK., Ibid., p 95 7 ceived it from others. Some get better, Ostes, J.K., Ibid., p. 99. / 8. Masterton, M.B., et xl., Curr. from all backgrounds. It is striking Med. Rex. Opin., 3, 83, 1975. 9. Sawyer, P.R., et xl., some get worse and some remain the Drugs, 9:424, 1975. / 10. Postgrad. Med. J., 50 Suppl., how people from the working class 54-76, 1975. can become quite psychological- same, but I have never felt sure that For further prescribing information please consult the post hoc ergo propter hoc. When I Canesten Product Monograph or your Boehringer Irigelheim minded after some experience in ther- representative with the educated classes meet the psychological-minded I * FBA Pharmaceuticals Ltd. apy, while wince. Distributed by: it may be impossible to break through Boehringer Ingeiheim (Canada) Ltd. intellectual rationalizations of destruc- ELLIOTr EMANUEL, MO FBA 2121 Trans Canada Highway 352 Dorval Ave. Dorval, P.Q. H9P 1J3 tive behaviour. Dorval, PQ FBA-65-76 1132 CMA JOURNAL/JUNE 19, 1976/VOL. 114