Episode #8 – A Sore Throat to Remember

Management of Lemierre’s syndrome

Source control

• Some patients may require interventional procedures or drainage if there is collection or abscess 
• In the past, sometimes there was ligation or resection of the internal jugular vein!

Antibiotic therapy

• Empiric therapy should target F.necrophorum and oral Strep.  
  • • Fusobacterium is fairly susceptible to a wide range of antibiotics:
    • Possible regimens: Ceftriaxone + Metronidazole; Pip-Tazo; Carbapenem
• May need empiric MRSA coverage if severe disease or risk factors
• Learning points from Thea: 
  • • There is a concern that even if you do not identify oral Strep in cultures, there might be a component of this in the infection → so would not use metronidazole monotherapy as initial therapy. It’s unclear if this is an ongoing issue though, so may be able to narrow to Metronidazole later in therapy if improved
    • Even if Fusobacterium spp is beta-lactamase negative, there is some concern and reports of treatment failure with penicillin or ampicillin alone.  The theory is that oral Strep that are also present might produce beta-lactamase that breaks down the PCN/Amp, even if the Fusobacterium itself is susceptible to it
• Duration is guided by clinical circumstances
  • • Typically patients receive at least 4 wks of therapy, often with 2 wks that are parenteral
    • Adjust based on the complications of metastatic infection, such as pulmonary abscess, septic arthritis
• There is a huge range of different regimens and treatment durations in the literature.  It has never really been studied, and these recommendations are based on case series mostly (no randomized trials).  We don’t really know!
• Clinical response to treatment can be slow

Anticoagulation

• It is unclear whether anticoagulation may reduce propagation of thrombus or septic embolic events from the IJV thrombosis, and data is mostly limited to anecdote and case reports.
• Many would lean against anticoagulation unless there is progression of thrombosis; continued fever; persistent bacteremia (after 5-7 days of appropriate antimicrobial therapy and appropriate source control wtih drainage of purulent collections as appropriate)
• If anticoagulation is used:
  • • Typically guided by hematology colleagues!
    • Clinical endpoint is uncertain, but likely discontinue when patient has clinical improved and imaging suggests thrombus extension has ceased. The range of anticoagulation duration reported though is quite large, often anywhere from a few weeks to 6 months.
    • >6 wks if embolic disease or underlying prothrombotic risk factors
• As Thea points out, sometimes this decision is informed by tradition and what folks have done before
• A few papers:
  • Phua CK, Chadachan VM, Acharya R. Lemierre syndrome-should we anticoagulate? A case report and review of the literature. Int J Angiol. 2013;22(2):137-142. doi:10.1055/s-0033-1336828
  • Nygren D, Elf J, Torisson G, Holm K. Jugular Vein Thrombosis and Anticoagulation Therapy in Lemierre’s Syndrome–A Post Hoc Observational and Population-Based Study of 82 Patients. Open Forum Infect Dis. 2020;8(1):ofaa585. Published 2020 Nov 29. doi:10.1093/ofid/ofaa585
  • Phan T, So TY. Use of anticoagulation therapy for jugular vein thrombus in pediatric patients with Lemierre’s syndrome. Int J Clin Pharm. 2012;34(6):818-821. doi:10.1007/s11096-012-9684-5
  • Cupit-Link MC, Nageswara Rao A, Warad DM, Rodriguez V. Lemierre Syndrome: A Retrospective Study of the Role of Anticoagulation and Thrombosis Outcomes. Acta Haematol. 2017;137(2):59-65. doi:10.1159/000452855