Treatment of Phlebitis
Remove the catheter immediately—this is the single most critical intervention and is mandatory, not optional. 1, 2
Immediate Management
The cornerstone of phlebitis treatment is prompt catheter removal when signs develop (warmth, tenderness, erythema, palpable venous cord). 1, 2 This is the most common error in management—failing to remove the catheter quickly enough. 2
For catheter-related phlebitis:
- Remove the peripheral IV catheter immediately 1, 2
- Submit any exudate from the insertion site for Gram staining and culture (including fungal and acid-fast organisms in immunocompromised patients) 2
- Do NOT use anticoagulation routinely for simple catheter-related phlebitis 2
Symptomatic Treatment
After catheter removal, provide supportive care:
- Apply warm compresses to the affected area 2
- Elevate the affected limb 2
- Use NSAIDs for pain control 2
- Encourage ambulation and exercise rather than bed rest 3
Topical treatments can help with local symptoms:
- Topical NSAID creams applied locally control symptoms 3
- Heparinoid cream (Hirudoid) shortens duration of signs/symptoms 3
When Anticoagulation IS Indicated
Anticoagulation becomes necessary when superficial vein thrombosis extends significantly:
For superficial vein thrombosis ≥5 cm in length: Use fondaparinux 2.5 mg subcutaneously daily for 45 days (preferred), or rivaroxaban 10 mg orally daily for 45 days if parenteral therapy is not feasible 2
For thrombosis within 3 cm of the saphenofemoral junction: Use therapeutic-dose anticoagulation for at least 3 months 2
The evidence strongly supports fondaparinux: In a large placebo-controlled trial of 3,002 participants, fondaparinux significantly reduced symptomatic VTE (RR 0.15), superficial thrombophlebitis extension (RR 0.08), and recurrence (RR 0.21) with no increase in major bleeding. 4
Special Considerations for Septic Phlebitis
Septic phlebitis presents with local syndrome, irregular fever pattern, positive blood cultures, and risk of infected emboli. 5
Management approach:
- Remove the causative catheter immediately 5, 6
- Start empiric antibiotics 24-36 hours after catheter removal, with vancomycin coverage given high rates of methicillin resistance 2
- Do NOT use heparin or anti-inflammatory agents (especially no corticoids) 5
- If clinical deterioration occurs or septicemia persists after 24 hours despite conservative therapy, consider surgical excision of the involved vein 6
Prevention Strategies
To prevent future episodes:
- Replace peripheral venous catheters every 72-96 hours in adults 1, 2
- Use upper extremity sites preferentially over lower extremity sites 1, 2
- Consider midline catheters or PICCs when IV therapy will likely exceed 6 days 1, 2
- In pediatric patients, leave catheters in place until IV therapy is completed unless complications occur 1
- Avoid steel needles for medications that might cause tissue necrosis if extravasation occurs 1