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]

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.

• 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 at 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 assessed utilizing an acid-fast bacilli analysis 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.

• C reactive protein over 13 mg/L
• CBC with marked left shift
• Elevated creatinine level
• 2 to 3 times the upper level of normal creatinine phosphokinase
• Low bicarbonate level

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.

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

=Acute Lymphangitis

• Preferred regimen: Dicloxacillin
• Preferred regimen: Cephalexin 500 mg PO qid for 1 week

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

• Trimethoprim-sulfamethoxazole PO bid AND vancomycin 1 g IV every 12 hr

• 3.Patient with lymphangitis allergic to penicillin:

• Clindamycin 300 mg PO qid for 7 days OR Erythromycin 500 mg PO qid for 7 days OR Levofloxacin 500 mg PO daily OR Moxifloxacin 400 mg PO daily for 7 days.

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

▸ 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. J Emerg Med. 2013 Jun;44(6):e397-412.Clin Infect Dis. 2011 Feb 1;52(3):e18-55.

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

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

Brugia Malayi Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO Adapted from Parasites - Lymphatic Filariasis CDC page.

Wuchereria Bancrofti Preferred Regimen ▸ Diethylcarbamazine 6 mg/kg/day PO Adapted from Parasites - Lymphatic Filariasis CDC page.