What are the treatment guidelines for infectious lymphadenitis?

Treatment Guidelines for Infectious Lymphadenitis

Complete excisional surgery without antibiotics is the recommended primary treatment for nontuberculous mycobacterial (NTM) cervical lymphadenitis, with a success rate of approximately 95%. 1

Etiological Approach to Treatment

Bacterial Lymphadenitis

Uncomplicated Bacterial Lymphadenitis

• First-line treatment: Narrow-spectrum beta-lactam antibiotics
  • Flucloxacillin or first-generation cephalosporins 2
  • Cloxacillin has been shown to be non-inferior to amoxicillin-clavulanic acid in pediatric bacterial lymphadenitis 3

Complicated Bacterial Lymphadenitis (with abscess formation)

• Management approach:
  1. Early imaging
  2. Prompt surgical intervention (incision and drainage)
  3. Antibiotic therapy:
     • In areas with low MRSA prevalence: Beta-lactam antibiotics
     • In areas with high MRSA prevalence: Consider clindamycin 2

Nontuberculous Mycobacterial (NTM) Lymphadenitis

Primary Treatment

• Complete excisional surgery without antibiotics 1
  • Avoid incisional biopsy alone as it may lead to persistent disease, sinus tract formation, and chronic drainage

High Surgical Risk Cases

• Clarithromycin-based multidrug regimen:
  • Clarithromycin (500-1,000 mg daily) or azithromycin (250 mg daily)
  • Plus rifampin (600 mg) or rifabutin (150-300 mg)
  • Plus ethambutol (15 mg/kg) 1
  • Treatment duration: 6-12 months

Severity-Based Treatment

• Mild cases: Usually require no treatment
• Symptomatic cases: Itraconazole (200 mg 3 times daily for 3 days, then once or twice daily for 6-12 weeks)
• Severe cases with compression: Prednisone (0.5-1.0 mg/kg daily, maximum 80 mg) in tapering doses over 1-2 weeks, with itraconazole to prevent progressive infection 1

Recurrent Disease

• A second surgical procedure is recommended 1

Special Considerations

Risk Factors for Treatment Failure

• Overlying skin changes and multiple or bilateral nodal disease are significantly associated with recurrence or development of new lesions 4
• For these high-risk presentations, consider more aggressive management with both surgical excision and antibiotics

Diagnostic Considerations

• When empiric antibiotics fail, re-evaluate diagnosis to determine:
  1. Need for surgical intervention
  2. Possibility of alternative microbiologic diagnoses 5

Suspected Tuberculosis

• If a child has granulomatous disease with a strongly positive PPD tuberculin skin test (≥15 mm), initiate anti-TB therapy while awaiting lymph node culture results, especially with TB risk factors 1

Antibiotic Selection Based on Likely Pathogens

• Most common pathogens in acute bacterial lymphadenitis:

  • Staphylococcus aureus (MSSA most common)
  • Group A Streptococcus 2

• Empiric therapy considerations:

  • Local resistance patterns should guide antibiotic choice, particularly regarding MRSA prevalence 5
  • In low MRSA prevalence settings, narrow-spectrum beta-lactams are appropriate for uncomplicated disease 2

Treatment Duration

• For bacterial lymphadenitis: 7-14 days of antibiotics typically sufficient for uncomplicated cases
• For NTM lymphadenitis requiring antimicrobial therapy: 6-12 months 1

Monitoring and Follow-up

• Monitor for:
  1. Defervescence (typically within 5-6 days of appropriate therapy) 3
  2. Reduction in lymph node size
  3. Decreased tenderness
  4. Normalization of inflammatory markers (leukocytosis, ESR, CRP)

Complications and Adverse Effects

• Surgical complications occur in approximately 15% of procedures 4
• Antibiotic-associated adverse effects occur in about 37% of patients receiving antimicrobial therapy for NTM lymphadenitis 4