What is the treatment for lymphangitis?

Treatment of Lymphangitis

Lymphangitis should be treated with appropriate antibiotics targeting the causative organism, with consideration for surgical intervention in specific cases such as non-tuberculous mycobacterial lymphadenitis. 1

Etiology and Diagnosis

• Lymphangitis is an inflammation of lymphatic channels that presents with characteristic linear erythematous streaks extending toward regional lymph nodes 2
• Common causes include bacterial infections, arthropod bite reactions, and non-infectious agents 2
• Diagnosis is primarily clinical, based on the presence of linear erythematous streaks and associated symptoms 2

Treatment Approach

Bacterial Lymphangitis

• For bacterial lymphangitis, appropriate antibiotic therapy is the mainstay of treatment 3, 1
• Common causative organisms include streptococci and staphylococci, which are typically involved in cellulitis with lymphangitis 3
• Any overlying eschar should be debrided before administering therapy to maximize treatment effect 3
• Secondary bacterial infections should be managed appropriately to ensure effective treatment 3

Antibiotic Selection

• For typical bacterial lymphangitis:
  • Penicillin (500 mg four times daily) or amoxicillin (500 mg three times daily) for 7-10 days is recommended 3
  • For penicillin-allergic patients, cephalosporins, clindamycin, or fluoroquinolones are appropriate alternatives 3

Special Considerations

Non-Tuberculous Mycobacterial (NTM) Lymphadenitis

• Excisional surgery without chemotherapy is the primary treatment for NTM cervical lymphadenitis, with approximately 95% success rate 1
• Incisional biopsy alone should be avoided as it may lead to persistent disease, sinus tract formation, and chronic drainage 1
• For recurrent disease or when surgical risk is high, a clarithromycin-based multidrug regimen may be considered 1

Borrelial Lymphocytoma (Lyme Disease)

• For lymphangitis associated with Lyme disease, oral antibiotic therapy for 14 days is recommended 1
• Options include:
  • Doxycycline (100 mg twice daily) 3, 1
  • Amoxicillin (500 mg three times daily) 3, 1
  • Cefuroxime axetil (500 mg twice daily) 3, 1

Recurrent Lymphangitis

• For patients with recurrent episodes of lymphangitis, especially those with underlying lymphedema, antibiotic prophylaxis has shown effectiveness 4
• Addressing underlying conditions such as tinea pedis is crucial to prevent recurrence in recurrent lymphangitic cellulitis syndrome 5

Management of Specific Causes

Nodular Lymphangitis

• Nodular lymphangitis (characterized by nodules along lymphatic channels) is commonly caused by Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, Leishmania braziliensis, and Francisella tularensis 6
• Treatment should target the specific organism identified through appropriate biopsies and cultures 6
• For tularemia-associated lymphangitis:
  • Streptomycin (15 mg/kg every 12 hours IM) or gentamicin (1.5 mg/kg every 8 hours IV) for severe cases 3
  • Tetracycline (500 mg four times daily) or doxycycline (100 mg twice daily) for mild cases 3

Prevention of Recurrence

• For patients with lymphedema complicated by recurrent lymphangitis, antibiotic prophylaxis has shown effectiveness in preventing subsequent attacks 4
• Treating underlying conditions that provide portals of entry for bacteria (such as tinea pedis or skin fissures) is essential to prevent recurrence 5
• Proper skin care and avoiding trauma to affected limbs are important preventive measures 5

Common Pitfalls

• Assuming all lymphangitis is bacterial in nature and unnecessarily prescribing antibiotics when non-infectious causes are present 2
• Failing to debride overlying eschar before administering therapy 3
• Not addressing underlying conditions that predispose to recurrent infections 5
• Performing incisional biopsy alone for NTM lymphadenitis, which can lead to chronic drainage and sinus tract formation 1