Treatment of Phlebitis
Remove the peripheral intravenous catheter immediately—this is the single most critical intervention and the most common error is failing to do so promptly enough. 1, 2
Immediate Management Steps
Catheter removal is mandatory, not optional. The following steps should be taken as soon as phlebitis is identified:
- Remove the IV catheter immediately upon appearance of any signs including warmth, tenderness, erythema, palpable venous cord, induration, or exudate 1, 3, 2
- Submit any exudate for culture (Gram stain, bacterial culture, and fungal/acid-fast organisms in immunocompromised patients) 1
- Do not delay catheter removal—this is the most frequent management error 1
Symptomatic Treatment
All patients with phlebitis should receive the following conservative measures:
- Apply warm compresses to the affected area to alleviate symptoms 1, 3, 4
- Administer NSAIDs for pain control (avoid if platelets <20,000-50,000/mcL) 1, 3
- Elevate the affected limb to reduce inflammation 1, 3, 4
- Encourage early mobilization rather than bed rest, as ambulation reduces DVT risk 3, 4
Topical heparinoid creams (Hirudoid) may shorten symptom duration, though availability varies by region 4
Critical Diagnostic Step: Ultrasound Evaluation
Obtain compression ultrasound to determine if anticoagulation is needed—approximately 25% of patients with superficial thrombophlebitis have underlying deep vein thrombosis. 3
The ultrasound must assess three key elements:
- Length of thrombus: If ≥5 cm, prophylactic anticoagulation is indicated 3
- Distance from saphenofemoral junction: If <3 cm, treat as DVT with therapeutic anticoagulation for ≥3 months 1, 3
- Presence of concomitant DVT: Requires full therapeutic anticoagulation 3
Anticoagulation Algorithm
For Thrombus <5 cm or Localized Injection Site Phlebitis
For Thrombus ≥5 cm in Lower Limb
Initiate prophylactic anticoagulation for 45 days with one of the following options: 1, 3
- First-line: Fondaparinux 2.5 mg subcutaneously once daily (check renal function before prescribing) 1, 3
- Alternative: Rivaroxaban 10 mg orally once daily (if parenteral therapy not feasible) 1, 3
- Less preferred: Low molecular weight heparin at prophylactic dose 3
For Thrombus Within 3 cm of Saphenofemoral Junction
Special Considerations for Septic Phlebitis
If infection is suspected (fever, purulent drainage, systemic signs):
- Consider empiric vancomycin given high rates of methicillin-resistant Staphylococcus aureus 1
- Antibiotics are NOT routinely indicated for simple catheter-related phlebitis without infection 4
- Surgical excision of the involved vein should be performed if clinical deterioration occurs or septicemia persists after 24 hours despite conservative therapy 5
Prevention Strategies
To reduce future phlebitis risk:
- Replace peripheral venous catheters every 72-96 hours in adults 1, 3, 2
- Use upper extremity sites preferentially over lower extremity sites 1, 2
- Consider midline catheters or PICCs when IV therapy will exceed 6 days 1, 2
- Use the smallest gauge catheter possible 1
- Prefer polyurethane or silicone catheters over Teflon 1
- Do NOT apply antimicrobial ointments prophylactically to catheter insertion sites 3
Critical Pitfalls to Avoid
- Do not omit ultrasound evaluation—25% have underlying DVT requiring different treatment 3
- Do not under-treat thrombosis close to the saphenofemoral junction—this requires therapeutic, not prophylactic anticoagulation 1, 3
- Do not prescribe bed rest—early mobilization reduces DVT risk 3, 4
- Do not use shorter treatment courses—evidence-based duration is 45 days for thromboses ≥5 cm 1, 3
- Do not leave the catheter in place—removal is mandatory 1, 2