What is the treatment for septic emboli?

Treatment of Septic Emboli

The treatment of septic emboli requires immediate removal of the infected catheter or source, prompt initiation of appropriate antimicrobial therapy, and in some cases, anticoagulation with heparin for central vein involvement. 1

Source Control

• Remove the involved catheter in all cases of septic thrombosis 1
• Perform incision, drainage, and excision of infected peripheral veins and involved tributaries, especially when there is suppuration, persistent bacteremia/fungemia, or metastatic infection 1
• Surgical exploration is necessary when infection extends beyond the vein into surrounding tissue 1
• Surgical excision and repair is required for peripheral arterial involvement with pseudoaneurysm formation 1

Antimicrobial Therapy

• Initiate empirical broad-spectrum antimicrobial therapy immediately upon diagnosis of septic emboli 1
• Administer antimicrobials within the first hour of documented hypotension in septic patients, as each hour of delay is associated with an average decrease in survival of 7.6% 1
• For empiric coverage, use one of the following options 1:
  • Meropenem or imipenem/cilastin
  • Piperacillin/tazobactam monotherapy
  • Ceftazidime (alternative option)
• Consider adding an aminoglycoside in cases of severe sepsis, though this increases risk of renal toxicity 1
• Add specific antibiotics (e.g., glycopeptide) if infection due to resistant bacteria is suspected, particularly for catheter-related sepsis 1
• For Candida septic thrombosis, administer a prolonged course of amphotericin B; fluconazole can be used if the strain is susceptible 1

Anticoagulation

• Use heparin for treatment of septic thrombosis of the great central veins and arteries 1
• Anticoagulation is not indicated for routine management of septic thrombosis of peripheral veins 1
• Thrombolytic agents in addition to antimicrobial agents are not recommended for catheter-related bloodstream infection with thrombus formation 1

Duration of Therapy

• For septic thrombosis of great central veins, antimicrobial therapy should be administered for 4-6 weeks (same as for endocarditis) 1
• In most cases of central vein thrombosis, vein excision is not required 1
• For persistent bacteremia or fungemia after catheter removal, treat presumptively for endovascular infection for 4 weeks of antimicrobial therapy 1

Management of Complications

Persistent Bloodstream Infection and Endocarditis

• Remove nontunneled catheters and most long-term catheters in cases of persistent bacteremia or fungemia 1
• Treat patients with repeatedly positive blood cultures and/or unchanged clinical status for 3 days after catheter removal with 4 weeks of antimicrobial therapy for presumed endovascular infection 1
• Empirical therapy must include coverage for staphylococci 1
• For Candida endocarditis, surgical intervention is required in addition to antimicrobial therapy in almost all cases 1

Supportive Care

• Implement aggressive and early goal-directed treatment to restore cardiovascular function within the first 6 hours 1
• Restore adequate cardiac filling pressures and maintain adequate organ perfusion (mean arterial pressure ≥65 mmHg, central venous pressure 8-12 mmHg) 1
• Use crystalloid fluids or colloids for volume substitution 1
• Monitor blood glucose levels and aim to keep blood glucose <150 mg/dL (<8.3 mmol/L) 1
• Provide deep vein thrombosis prophylaxis with low molecular weight heparin (LMWH) or unfractionated heparin (UFH) unless contraindicated 1
• Provide stress ulcer prophylaxis in patients with risk factors for GI bleeding 1

Special Considerations

• For septic pulmonary emboli, the most common causative pathogens are Klebsiella pneumoniae and Staphylococcus aureus 2
• The most common sources of septic pulmonary emboli requiring critical care are liver abscess (40%) and pneumonia (25%) 2
• In patients with septic emboli and neutropenia, symptoms may persist until neutropenia resolves despite appropriate antimicrobial therapy 3
• For MRSA sepsis presenting with septic pulmonary emboli, aggressive intravenous antibiotic therapy is essential 4

Pitfalls and Caveats

• Avoid delay in antimicrobial administration as this significantly increases mortality 1, 5
• Do not use human albumin for volume resuscitation as it is not associated with favorable outcomes 1
• Avoid unnecessary prolonged antimicrobial therapy to prevent superinfection with resistant organisms 1
• Do not use thrombolytic agents for treatment of septic thrombosis 1
• Be aware that septic pulmonary emboli in critically ill patients are associated with high mortality (30%), with pneumonia and liver abscess being the most common causes of death 2