What is the treatment for phlebitis?

Treatment of Phlebitis

Immediate Management

Remove the catheter immediately when phlebitis is identified—this is mandatory, not optional. 1, 2

• Peripheral intravenous catheters showing pain, induration, erythema, or exudate must be removed promptly 1
• Catheter removal is the single most critical intervention and the most common error is failing to remove it quickly enough 2
• Submit any exudate from the insertion site for Gram staining and culture (including fungal and acid-fast organisms in immunocompromised patients) 1

Symptomatic Treatment

After catheter removal, provide supportive care to manage local symptoms:

• Apply warm compresses to the affected area 3
• Elevate the affected limb 3
• Use NSAIDs for pain control 3, 4
• Encourage early ambulation rather than bed rest (bed rest increases DVT risk) 4
• Consider topical NSAIDs or heparinoid creams (such as Hirudoid) to reduce local inflammation and shorten symptom duration 4, 5

When to Consider Anticoagulation

Anticoagulation is NOT routinely indicated for simple catheter-related phlebitis. 1 However, specific circumstances require prophylactic anticoagulation:

• If superficial vein thrombosis extends ≥5 cm in length, treat with fondaparinux 2.5 mg subcutaneously daily for 45 days 3, 6
• Alternative: rivaroxaban 10 mg orally daily for 45 days if parenteral therapy is not feasible 3
• If thrombosis is within 3 cm of the saphenofemoral junction, use therapeutic-dose anticoagulation for at least 3 months 3
• For high-risk patients (active cancer, history of VTE, extensive involvement), prophylactic LMWH may be considered 1, 3

Prevention Strategies

To minimize future phlebitis risk:

• Replace peripheral venous catheters every 72-96 hours in adults 2
• Use upper extremity sites preferentially over lower extremity sites 2
• Consider midline catheters or PICCs when IV therapy will exceed 6 days 1, 2
• Use the smallest gauge catheter possible (ideally catheter diameter should be one-third or less of vein diameter) 1
• Prefer polyurethane or silicone catheters over Teflon 1
• Ensure proper catheter fixation and aseptic technique during insertion and care 1
• Monitor infusion osmolarity and pH (maintain pH between 5-9) 1

Special Considerations for Septic Phlebitis

If systemic signs of infection develop (fever, persistent bacteremia, clinical deterioration):

• Start empiric antibiotics covering Staphylococcus aureus (most common pathogen, 41% of cases) and streptococci 7
• Consider vancomycin for empiric coverage given high rates of methicillin resistance 1
• If the patient deteriorates or septicemia persists after 24 hours despite antibiotics and catheter removal, surgical excision of the involved vein may be necessary 7
• Complications occur in 56% of septic phlebitis cases, with average hospital stay of 14 days after diagnosis 7

Critical Pitfalls to Avoid

• Failing to remove the catheter promptly is the most common and serious error 2
• Do not treat simple infusion phlebitis with anticoagulation unless there is documented thrombosis meeting criteria above 3
• Do not prescribe bed rest—early ambulation reduces DVT risk 4
• Do not assume antibiotics are needed for non-infectious phlebitis 4