Excerpt from Thrombophlebitis, Septic

Synonyms, Key Words, and Related Terms: septic phlebitis, septic thrombophlebitis, septic emboli, septic shock, catheter-related septic phlebitis, suppurative superficial thrombophlebitis, septic pelvic thrombophlebitis, septic ovarian vein thrombophlebitis, septic pelvic phlebitis

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Background: The clinical course and severity of septic thrombophlebitis are quite variable. Many cases present as benign localized lesions that require minimal intervention after which complete recovery is expected. Some cases present as severe systemic infections culminating in profound shock, refractory even to aggressive management, including operative intervention and appropriate treatment in the intensive care unit.

The approach to septic phlebitis depends on which veins are involved, the underlying etiology of the phlebitis, which organisms are involved, and the patient's underlying physiology.

Peripheral septic thrombophlebitis is a common problem that can develop spontaneously but more often is associated with breaks in the skin. Peripheral septic phlebitis is most commonly caused by intravenous catheters, venipuncture for phlebotomy, or intravenous injection. Septic phlebitis may produce septic emboli, which can seed distant sites. Extensive showering of septic emboli may initiate a systemic inflammatory response, culminating in septic shock, which has a poor prognosis even when managed ideally.

Catheter-related septic phlebitis is one of the most common causes of fever after the third postoperative day. Catheter-associated phlebitis may develop at any site but is most frequent after cannulation of lower limb veins and veins at the groin. Catheter-related phlebitis also can result from chemical or mechanical irritation without infection, but infection must be strongly suspected in any patient with catheter-related phlebitis. Sterile superficial phlebitis should be evaluated and managed as discussed in Thrombophlebitis, Superficial.

Septic phlebitis of a superficial vein without frank purulence is known as simple phlebitis. Simple phlebitis can be benign, but when progressive, it may cause serious complications including death.

Suppurative superficial thrombophlebitis, in which actual purulent material can be expressed from a vein, portends a much poorer prognosis. Such cases are often associated with frank sepsis and therefore confer a substantial risk of mortality even when treated aggressively. Patients with this condition are likely to appear toxic (eg, high fevers, rigors, sweats, chills, altered sensorium, poor urine output).

Septic phlebitis of the deep veins is a life-threatening emergency that may fail to respond to even the most aggressive therapy. Septic pelvic thrombophlebitis and septic ovarian vein thrombophlebitis are seen principally as complications of puerperal infection and septic abortion. Occasionally, septic pelvic phlebitis may be secondary to pelvic inflammatory disease or progressive infection of the urinary tract. In diverticulitis, infection may spread to cause septic phlebitis of the portal venous system (pylephlebitis).

Lemierre syndrome is an anaerobic suppurative thrombophlebitis of the internal jugular vein, most commonly as a complication of pharyngeal, dental, or mastoidal infection. Lemierre syndrome is much more common than generally appreciated, and it may be complicated by septic emboli. Septic emboli can lodge in the lungs (septic pulmonary emboli). Less commonly, septic emboli may traverse a patent foramen ovale resulting in distant metastatic infections. Secondary infections may include septic arthritis, paravertebral abscess, cutaneous abscess, periorbital cellulitis, meningitis, and osteomyelitis.

Thrombophlebitis of the intracranial venous sinuses is a particularly serious problem. Infection of the medial third of the face is associated with cavernous sinus thrombophlebitis. Mastoiditis is associated with septic phlebitis involving the lateral sinuses. Cases of intracranial septic thrombophlebitis are fatal in more than a third of cases.

Pathophysiology: Septic phlebitis can develop spontaneously or as a re .....