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Revision as of 14:24, 12 June 2014

Lymphangitis Microchapters

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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 should be promptly diagnosed and treated with appropriate antibiotics along with analgesics, anti inflammatory medications. Symptomatic relief with warm and moist compresses can be utilized as well.

General Principles of Therapy Adapted from Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases.[1]

  • Prompt empirical antibiotic therapy that mostly covers beta-hemolytic streptococci should be started in order to prevent the rapid progression of lymphangitis.
  • Staphylococcal infection should be suspected if prominent suppuration is observed in the primary site of infection.
  • If the patient does not respond to the initial empirical antibiotic therapy, present with symptoms of systemic toxicity or if the prevalence of methicillin-resistant staphylococcus aureus (MRSA) infections is high in the community, empirical coverage should be considered.
  • Patients with mild to moderate disease can be managed in an outpatient setting and patients with severe disease should be managed in an inpatient setting.
  • While treating the patients with antibiotics, the following should be considered:
    • Carbapenems should not be used in patients with a history of hypersensitivity to beta-lactams.
    • TMP-SMX is not recommended for women in the third trimester of pregnancy and in children under 2 months of age.
    • Tetracyclines should not be used in children under 8 years of age.
  • Besides antibiotics, analgesics, anti inflammatory medications, hot and moist compresses can be used to control pain and inflammation.
  • The chronic sporotrichoid form of lymphangitis can be treated with chemotherapy.
  • When Mycobacterium marinum infection is suspected, confirmation should be done by acid-fast bacilli observation and organism isolation.
  • Recurrent lymphangitis can lead to chronic lymphedema, which can be treated with leg elevation, intermittent pneumatic compressions, manual massages, and multilayered bandage wrapping.
  • Lymphatic filariasis can be treated with a one-day or a 12-day diethylcarbamazine regimen. The one-day regimen is as effective as the 12-day regimen.

Laboratory Findings of Severe Disease Adapted from the 2005 IDSA Practice guidelines for the diagnosis and management of skin and soft-tissue infections.[2]

Signs and Symptoms Suggestive of Severe Infection Adapted from the 2005 IDSA Practice guidelines for the diagnosis and management of skin and soft-tissue infections.[2]

  • Hypotension
  • Cutaneous hemorrhage
  • Disproportional pain
  • Gas in the tissue
  • Skin sloughing
  • Violaceous bullae

Specific Therapy Based on Clinical Form of Lymphangitis

Acute Lymphangitis

Empiric Therapy Adapted from Clin Infect Dis. 2005 Nov 15;41(10):1373-406.[2] J Emerg Med. 2013 Jun;44(6):e397-412.[3]Clin Infect Dis. 2011 Feb 1;52(3):e18-55.[4]

▸ 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
Doxycycline 100 mg PO q12h
OR
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 < 12 years-old 25-50 mg/kg/day PO divided q6-8h (maximum 3 g/day), > 12 years-old 250-500 mg PO q6-8h
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
Not recommended for children < 8 years of age
For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA)
Clindamycin 10-13 mg/kg IV q6-8h
OR
Amoxicillin 500 mg PO q8h
PLUS
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
Not recommended for children < 8 years of age
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 1-2 g IV q4h
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 600 mg PO/IV q8h
OR
Linezolid 600 mg PO/IV 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 100–150 mg/kg IV q6h
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
For Suspected Beta-Hemolytic Streptococci and Methicillin-Resistant Staphylococcus Aureus (MRSA)
Clindamycin 10-13 mg/kg IV q6-8h
OR
Linezolid 10 mg/kg IV/PO q8h
For Animal Bites
Ampicillin sulbactam 50 mg/kg IV q6h

Pathogen Based Therapy Adapted from Clin Infect Dis. 2005 Nov 15;41(10):1373-406.[2] J Emerg Med. 2013 Jun;44(6):e397-412.[3]Clin Infect Dis. 2011 Feb 1;52(3):e18-55.[4]

▸ 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 1-2 g IV q4h
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 100 mg PO q12h
OR
Minocycline 100 mg PO q12h
OR
TMP-SMX 1 or 2 double-strength tablets ((sulfamethoxazole 800 mg; trimethoprim 160 mg) PO q12h
Children age >28 days
Nafcillin 100–150 mg/kg IV q6h
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-SMX 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Preferred Regimen
Adults
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 100 mg PO q12h
OR
Minocycline 100 mg PO q12h
OR
TMP-SMX 1 or 2 double-strength tablets (800/160 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-SMX 8–12 mg/kg (based on trimethoprim component) IV q6h/PO q12h
Pasteurella Multocida
Preferred Regimen
Adults
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
OR
Ertapenem 1 g IM/IV q24h
Alternative Regimen
Adults
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
PLUS
Clindamycin 450 mg PO or 600 mg IV q8h
OR
TMP-SMX 1 double strength tablet (800/160 mg) PO q12h or 8-20 mg/kg IV divided q6-12h
PLUS
Clindamycin 450 mg PO or 600 mg IV q8h
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
PLUS
Ethambutol 15 mg/kg PO q24h
Adapted from

Eur J Clin Microbiol Infect Dis. 2006 Oct;25(10):609-13.[5] Am J Respir Crit Care Med. 2007 Feb 15;175(4):367-416.[6]

Sporothrix Schenckii
Preferred Regimen
Itraconazole 200 mg PO q24h
Alternative Regimen†
Itraconazole 200 mg PO q12h
OR
Terbinafine 500 mg PO q12h
OR
Saturated solution of potassium iodide 5-50 drops q8h
OR
Fluconazole¶ 400-800 mg/day PO
If there is no improvement after preferred treatment
Only administer if patient can't tolerate other antifungal agents
Adapted from Clin Infect Dis. 2007 Nov 15;45(10):1255-65. Epub 2007 Oct 8 [7]
Brugia Malayi
Preferred Regimen
Diethylcarbamazine 6 mg/kg/day PO
Adapted from Parasites - Lymphatic Filariasis CDC page. [8]
Wuchereria Bancrofti
Preferred Regimen
Diethylcarbamazine 6 mg/kg/day PO
Adapted from Parasites - Lymphatic Filariasis CDC page. [8]

References

  1. Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier.
  2. 2.0 2.1 2.2 2.3 Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ; et al. (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clin Infect Dis. 41 (10): 1373–406. doi:10.1086/497143. PMID 16231249.
  3. 3.0 3.1 Moran GJ, Abrahamian FM, Lovecchio F, Talan DA (2013). "Acute bacterial skin infections: developments since the 2005 Infectious Diseases Society of America (IDSA) guidelines". J Emerg Med. 44 (6): e397–412. doi:10.1016/j.jemermed.2012.11.050. PMID 23466022.
  4. 4.0 4.1 Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ; et al. (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clin Infect Dis. 52 (3): e18–55. doi:10.1093/cid/ciq146. PMID 21208910.
  5. Petrini B (2006). "Mycobacterium marinum: ubiquitous agent of waterborne granulomatous skin infections". Eur J Clin Microbiol Infect Dis. 25 (10): 609–13. doi:10.1007/s10096-006-0201-4. PMID 17047903.
  6. Griffith DE, Aksamit T, Brown-Elliott BA, Catanzaro A, Daley C, Gordin F; et al. (2007). "An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases". Am J Respir Crit Care Med. 175 (4): 367–416. doi:10.1164/rccm.200604-571ST. PMID 17277290.
  7. Kauffman CA, Bustamante B, Chapman SW, Pappas PG, Infectious Diseases Society of America (2007). "Clinical practice guidelines for the management of sporotrichosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (10): 1255–65. doi:10.1086/522765. PMID 17968818.
  8. 8.0 8.1 "Parasites - Lymphatic Filariasis".

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