What is the recommended treatment for lymphadenitis?

Treatment of Lymphadenitis

The recommended treatment for lymphadenitis depends on the causative organism, with surgical excision being the primary treatment for non-tuberculous mycobacterial (NTM) lymphadenitis, while bacterial lymphadenitis typically requires appropriate antibiotic therapy based on the suspected pathogen. 1, 2

Bacterial Lymphadenitis

Uncomplicated Bacterial Lymphadenitis

• Narrow-spectrum beta-lactam antibiotics (flucloxacillin or first-generation cephalosporins) are the mainstay of therapy for uncomplicated bacterial lymphadenitis in regions with low MRSA prevalence 2
• Common causative organisms include methicillin-susceptible Staphylococcus aureus (MSSA) and Group A Streptococcus, which together account for over 90% of culture-positive cases 2
• Treatment duration typically ranges from 7-14 days depending on clinical response 3

Complicated Bacterial Lymphadenitis (with abscess formation)

• Requires more aggressive management including:
  • Early imaging to identify collections 2
  • Surgical drainage of abscesses 3
  • Broader antibiotic coverage, potentially including clindamycin in areas with higher MRSA prevalence 2
• Patients typically present later, require longer hospital stays, and need longer courses of antibiotics 2

Non-Tuberculous Mycobacterial (NTM) Lymphadenitis

Primary Treatment Approach

• Excisional surgery without chemotherapy is the recommended treatment for children with NTM cervical lymphadenitis, with a success rate of approximately 95% 1
• Incisional biopsy alone or anti-TB drugs without macrolides should be avoided as they frequently lead to persistent disease, sinus tract formation, and chronic drainage 1

Alternative/Adjunctive Approaches

• For recurrent disease or when surgical risk is high (e.g., risk of facial nerve involvement with preauricular nodes), a clarithromycin-based multidrug regimen may be considered 1
• More aggressive management with both surgical excision and antibiotics is recommended for patients with:
  • Overlying skin changes
  • Multiple or bilateral nodal disease
  • As these factors are significantly associated with recurrence or new disease 4

Borrelial Lymphocytoma (Lyme Disease)

• For patients with borrelial lymphocytoma, oral antibiotic therapy for 14 days is recommended 1
• Oral antibiotic options include:
  • Doxycycline (100 mg twice daily for adults; 4 mg/kg/day in 2 divided doses for children ≥8 years)
  • Amoxicillin (500 mg three times daily for adults; 50 mg/kg/day in 3 divided doses for children)
  • Cefuroxime axetil (500 mg twice daily for adults; 30 mg/kg/day in 2 divided doses for children) 1

Special Considerations

Diagnostic Approach

• Surgical excision yields higher positive histological findings compared to fine-needle aspiration 4
• In cases where TB is suspected (e.g., positive PPD test), anti-TB therapy should be initiated while awaiting culture results, especially when risk factors for TB are present 1

Complications and Monitoring

• Surgical complications occur in approximately 15% of procedures 4
• Antibiotic-associated adverse effects occur in about 37% of patients treated with antibiotics 4
• Regular follow-up is essential to monitor treatment response and identify complications early 4

Pitfalls to Avoid

• Avoid incisional biopsy alone for NTM lymphadenitis as it can lead to chronic drainage and sinus tract formation 1
• Do not rely solely on anti-TB drugs without macrolides for NTM lymphadenitis 1
• Recognize that persistent symptoms after appropriate treatment may represent non-infectious inflammatory processes rather than ongoing infection 5