Do you anticoagulate (use anticoagulants) septic emboli?

Anticoagulation for Septic Emboli

Anticoagulation is NOT routinely recommended for septic emboli, with the important exception of septic thrombosis involving great central veins and arteries, where heparin should be used. 1

Key Distinction: Location Determines Treatment

The decision to anticoagulate septic emboli depends critically on the anatomic location of the septic thrombosis:

Great Central Veins and Arteries

• Use heparin for septic thrombosis of great central veins and arteries 1
• This represents the primary indication where anticoagulation is beneficial in the setting of septic emboli

Peripheral Veins

• Anticoagulation is NOT indicated for routine management of septic thrombosis of peripheral veins 1
• The risks outweigh benefits in these locations

IVC Filters Are Not Recommended

• The use of IVC filters in patients with septic emboli is not currently recommended given the risks of filter infection 2
• This recommendation is based on limited evidence (single animal study) and the substantial risk of device infection 2
• Retrievable filters may be removed if they become infected 2

Rationale for Limited Anticoagulation Use

The conservative approach to anticoagulation in septic emboli differs fundamentally from non-septic thromboembolism because:

• Septic emboli represent dual pathology: both embolic/ischemic insult from vascular occlusion AND infectious insult from a deep-seated infection source 3
• The infectious component creates risk for hemorrhagic complications including mycotic aneurysms and intravascular abscesses 3
• Thrombolytic agents in addition to antimicrobial agents are NOT recommended for catheter-related bloodstream infection with thrombus formation 1

General Sepsis Guidelines Do Not Support Routine Anticoagulation

The Surviving Sepsis Campaign guidelines make clear that:

• Antithrombin is specifically recommended AGAINST for treatment of sepsis and septic shock (strong recommendation, moderate quality evidence) 2
• No recommendation is made regarding the use of thrombomodulin or heparin for treatment of sepsis or septic shock 2
• This neutral stance on heparin for general sepsis does not constitute an endorsement for septic emboli treatment

Primary Treatment Focus: Source Control and Antibiotics

The cornerstone of septic emboli management is NOT anticoagulation but rather:

Source Control

• Remove involved catheters in all cases of septic thrombosis 1
• Perform incision, drainage, and excision of infected peripheral veins when there is suppuration, persistent bacteremia/fungemia, or metastatic infection 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 1
• Administer antimicrobials within the first hour of documented hypotension, as each hour of delay decreases survival by 7.6% 1
• Duration: 4-6 weeks of antimicrobial therapy for septic thrombosis of great central veins 1

Special Considerations in Infective Endocarditis

When septic emboli occur in the context of infective endocarditis (a common source):

• It is reasonable to temporarily discontinue anticoagulation in patients with IE who develop CNS symptoms compatible with embolism or stroke, regardless of other indications for anticoagulation 2
• Temporary discontinuation of vitamin K antagonist anticoagulation might be considered in patients receiving VKA at the time of IE diagnosis 2
• This reflects the high risk of hemorrhagic transformation of embolic strokes (up to 11 days post-infarct) 2

Common Pitfalls to Avoid

• Do NOT extrapolate VTE treatment guidelines to septic emboli - these are fundamentally different pathologic processes 2, 1
• Do NOT use thrombolytic agents for septic thrombosis 1
• Do NOT place IVC filters as a preventive measure for septic emboli given infection risk 2
• Do NOT delay antimicrobial administration while considering anticoagulation - antibiotics are the priority 1
• Reliance on anticoagulants alone to control emboli is dangerous and proper surgical intervention with antibiotic therapy reduces the need for long-term anticoagulation 4