Lymphangitis medical therapy

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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],Faizan Sheraz, M.D. [3]Vishal Devarkonda, M.B.B.S[4]

Overview

Lymphangitis being a manifestation of wide concurrently occurring spectrum of manifestations or pathologies.The medical therapy varies from etiology to etiology. The mainstay of therapy for lymphangitis of infectious origin is antimicrobial therapy. Supportive therapy includes analgesics, anti-inflammatory agents, and warm compresses. Specific anitmicrobial treatment for individual infections are discussed in detail separately.

Medical Therapy

The mainstay of therapy for lymphangitis of infectious origin is antimicrobial therapy. Supportive therapy includes analgesics, anti-inflammatory agents, and warm compresses.

[1]

Lymphangitis of infectious etiology

Common preferred and accepted therapy for lymphangitis of infectious origin include: Dicloxacillin or Cephalexin

  • 2. Patient with lymphangitis and if Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) suspected:
  • 3.Patient with lymphangitis allergic to penicillin:

Empiric Therapy Adapted from Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases.[2]Adapted from Clin Infect Dis. 2005 Nov 15;41(10):1373-406.[3] J Emerg Med. 2013 Jun;44(6):e397-412.[4]Clin Infect Dis. 2011 Feb 1;52(3):e18-55.[5]

▸ 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 (160/800 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
For Suspected Methicillin-Resistant Staphylococcus Aureus (MRSA)
Vancomycin 15-20 mg/kg IV q8-12h
OR
Linezolid 600 mg IV/PO 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 IV/PO q8h
OR
Linezolid 600 mg IV/PO 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/PO 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.[3] J Emerg Med. 2013 Jun;44(6):e397-412.[4]Clin Infect Dis. 2011 Feb 1;52(3):e18-55.[5]

▸ 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 Granulomatous 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.[6] Am J Respir Crit Care Med. 2007 Feb 15;175(4):367-416.[7]

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 [8]
Brugia Malayi
Preferred Regimen
Diethylcarbamazine 6 mg/kg/day PO
Adapted from Parasites - Lymphatic Filariasis CDC page. [9]
Wuchereria Bancrofti
Preferred Regimen
Diethylcarbamazine 6 mg/kg/day PO
Adapted from Parasites - Lymphatic Filariasis CDC page. [9]

Lymphantic Filarisis

Lymphangitis due to non-infectious etiology

Medical therapy for lymphangitis due to non-infectious etiology include:

Lymphangitic carcinomatosis

  • Currently, no effective strategies available in treating lymphangitis carcinomatosa [10]
  • Steroid administration could produce symptomatic improvement mainly by alleviating breathlessness.[11]
  • Poor prognosis[11]

Sclerosis Lymphangitis

  • Sclerosis lymphangitis is a self-limiting disease, resolving spontaneously within several weeks, if restrained from vigorous sexual activity.[12][13]
  • No treatment is required, NSAID's have been recommended but without proven benefit.

References

  1. lymphanitis Mandell, GERALD L. "Mandell, Douglas, and Bennett's." Principles and practice of infectious diseases 7 (1995) Accessed on October 12,2016
  2. 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.
  3. 3.0 3.1 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.
  4. 4.0 4.1 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.
  5. 5.0 5.1 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.
  6. 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.
  7. 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.
  8. 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.
  9. 9.0 9.1 9.2 "Parasites - Lymphatic Filariasis".
  10. Raja A, Seshadri RA, Sundersingh S (2010). "Lymphangitis carcinomatosa: report of a case and review of literature". Indian J Surg Oncol. 1 (3): 274–6. doi:10.1007/s13193-011-0047-9. PMC 3244248. PMID 22693377.
  11. 11.0 11.1 Bruce DM, Heys SD, Eremin O (1996). "Lymphangitis carcinomatosa: a literature review". J R Coll Surg Edinb. 41 (1): 7–13. PMID 8930034.

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