What is the recommended treatment for phlebitis?

Treatment of Phlebitis

For superficial thrombophlebitis ≥5 cm in length, treat with prophylactic-dose fondaparinux 2.5 mg subcutaneously daily for 45 days, which reduces progression to deep vein thrombosis and recurrent superficial thrombosis without increasing bleeding risk. 1

Initial Diagnostic Evaluation

• Obtain compression ultrasound immediately to confirm the diagnosis and exclude concurrent deep vein thrombosis, which occurs in approximately 25% of patients with superficial thrombophlebitis 1
• Assess the extent of thrombosis and proximity to the deep venous system 1
• Remove any intravenous catheters if present, as 54% of septic phlebitis cases are catheter-related 2

Treatment Algorithm by Type and Extent

Extensive Superficial Thrombophlebitis (≥5 cm or involving saphenous trunk)

First-line anticoagulation:

• Fondaparinux 2.5 mg subcutaneously once daily for 45 days reduces symptomatic VTE from 1.3% to 0.2% and recurrent superficial thrombosis from 1.6% to 0.3% 1, 3
• Alternative: Prophylactic-dose LMWH for 45 days if fondaparinux is unavailable 1
• Dalteparin is superior to NSAIDs in preventing thrombus extension at 14 days 4

Adjunctive measures:

• Elastic compression stockings 5
• Early ambulation and exercise (reduces pain and DVT risk) 5
• Topical NSAIDs or heparinoid creams for symptom control 5
• Avoid bed rest except when pain is severe 5

Limited Superficial Thrombophlebitis (<5 cm, not involving saphenous trunk)

• Topical NSAIDs or heparinoid cream 5
• Elastic compression 5
• Early ambulation 5
• Anticoagulation generally not required 1

Upper Extremity Superficial Thrombophlebitis (Cephalic/Basilic Veins)

• Anticoagulation not typically required 1
• Remove catheter if present and no longer functional 1
• Topical therapy and compression as needed 5

Septic Phlebitis

Immediate management:

• Remove intravenous device promptly 2
• Start empiric antibiotics covering Staphylococcus aureus (41% of cases) and Group A streptococcus (20% of cases) 2
• Heat and elevation 2

Escalation criteria:

• Perform surgical excision of involved vein if:
  • Clinical deterioration occurs 2
  • Septicemia persists after 24 hours despite conservative therapy 2
• Complications occur in 56% of cases, with average hospital stay of 14 days after diagnosis 2

Special Populations

Pregnancy

• Use LMWH (not fondaparinux, which crosses the placenta) for the remainder of pregnancy plus 6 weeks postpartum 1

Cancer-Associated Thrombophlebitis

• Consider therapeutic anticoagulation as active cancer is a risk factor for progression 1
• May require extended anticoagulation 5

Common Pitfalls to Avoid

• Failing to perform ultrasound to exclude concurrent DVT, which changes management entirely 1
• Inadequate treatment duration - 45 days is required for extensive disease, not shorter courses 1
• Prescribing antibiotics routinely - they are only indicated for documented infection, not sterile thrombophlebitis 5
• Enforcing bed rest - this increases DVT risk and should be avoided unless pain is severe 5
• Changing IV catheters too infrequently - should be changed every 24-48 hours to prevent catheter-related phlebitis 5