From the Guidelines
The treatment for acute lymphadenitis, specifically in the context of nontuberculous mycobacterial (NTM) diseases, is excisional surgery without chemotherapy, which has a success rate of approximately 95%. This approach is recommended for children with NTM cervical lymphadenitis, including those with disease caused by MAC and M. scrofulaceum 1. The use of excisional surgery is supported by evidence showing that it frequently leads to successful treatment, especially when diagnosis is made with fine needle aspiration or incisional biopsy.
In cases where surgical risk is high, such as risk of facial nerve involvement with preauricular nodes, or for children with recurrent disease, an alternative treatment approach may be considered, which includes the use of a clarithromycin multidrug regimen, similar to that used for pulmonary disease 1. However, experience with this approach is limited, and it should be considered on a case-by-case basis.
Key points to consider in the treatment of acute lymphadenitis include:
- Excisional surgery as the primary treatment for NTM cervical lymphadenitis
- The use of clarithromycin multidrug regimens as an alternative for high-risk or recurrent cases
- Avoidance of incisional biopsy alone or the use of anti-TB drugs alone without a macrolide, as these approaches have been associated with persistent clinical disease and complications such as sinus tract formation and chronic drainage 1
- The importance of considering the risk factors for TB, such as positive family history and foreign-born status, when making treatment decisions, especially in cases with a strongly positive PPD tuberculin skin test.
From the Research
Treatment Approaches for Acute Lymphadenitis
The treatment for acute lymphadenitis depends on the severity and cause of the condition.
- For uncomplicated cases, narrow-spectrum beta-lactam therapy, such as flucloxacillin or first-generation cephalosporins, is often effective 2.
- In cases where the disease is complicated, such as the presence of an abscess, treatment may involve a combination of antibiotics and surgical intervention 2, 3.
- The choice of antibiotic should be guided by the suspected or confirmed causative pathogen, with common causes including Staphylococcus aureus and Streptococcus pyogenes 4, 5, 6, 3.
- Empiric antibiotic therapy may be successful in the early stages of the disease, but increasing prevalence of methicillin-resistant S. aureus has necessitated a shift in antibiotic choice 5.
Antibiotic Selection
- Beta-lactam therapy, such as cefazolin, may be effective for methicillin-susceptible S. aureus lymphadenitis 4.
- Clindamycin may be used to treat complicated disease, particularly in cases where methicillin-resistant S. aureus is suspected or confirmed 2, 3.
- The use of broad-spectrum antibiotics, such as ampicillin-sulbactam, may not be necessary in all cases and may contribute to antibiotic resistance 4.