Antibiotic Treatment of Non-Tuberculous Lymphadenitis in Adults
Surgical excision without chemotherapy is the primary treatment for non-tuberculous mycobacterial (NTM) cervical lymphadenitis, with a macrolide-based antibiotic regimen reserved for patients with extensive disease, poor surgical response, or high surgical risk. 1
Primary Treatment Approach
Complete surgical excision alone achieves approximately 95% cure rates and is the recommended first-line treatment for NTM cervical lymphadenitis. 1 This approach applies to the majority of cases caused by Mycobacterium avium complex (MAC) and M. scrofulaceum. 1
When to Add Antibiotics
A macrolide-based antibiotic regimen should be considered in the following situations: 1
- Extensive MAC lymphadenitis involving multiple nodes or bilateral disease
- Poor response to initial surgical therapy including persistent clinical disease or recurrence
- High surgical risk such as proximity to facial nerve with preauricular nodes
- Residual disease after excision or inability to achieve complete excision
Antibiotic Regimen Recommendations
Standard Macrolide-Based Therapy
For adults requiring antimicrobial therapy, the recommended regimen mirrors that used for MAC pulmonary disease: 1
- Clarithromycin 500-1,000 mg daily OR Azithromycin 250 mg daily
- Plus Ethambutol 15 mg/kg daily
- Plus Rifampin 600 mg daily OR Rifabutin 150-300 mg daily
Species-Specific Considerations
For M. abscessus lymphadenitis, multidrug regimens including clarithromycin 1,000 mg/day may cause symptomatic improvement, though no regimens have proven or predictable efficacy. 1 Surgical debridement combined with clarithromycin-based therapy offers the best chance for cure. 1
For rapidly growing mycobacteria (RGM) including M. abscessus, M. chelonae, and M. fortuitum, treatment should be based on in vitro susceptibilities, with macrolide-based regimens frequently used. 1
Treatment Duration
Patients should be treated until culture negative on therapy for 1 year when antibiotics are used for pulmonary or disseminated MAC disease. 1 For localized extrapulmonary disease including lymphadenitis, 6 to 12 months of chemotherapy is usually recommended, though optimal duration is not definitively established. 1
Critical Pitfalls to Avoid
Incisional biopsy alone or anti-TB drugs without a macrolide frequently result in persistent clinical disease, sinus tract formation, and chronic drainage. 1 These approaches should be avoided. 1
Fine needle aspiration for diagnosis is acceptable, but definitive treatment requires either complete excision or appropriate antimycobacterial therapy. 1 Incision and drainage techniques have been associated with prolonged wound discharge and scarring. 1
Diagnostic Considerations
When granulomatous disease is found with a strongly positive PPD tuberculin skin test (≥15 mm), initiate anti-TB therapy while awaiting culture results, especially with TB risk factors such as positive family history or foreign-born status. 1 If cultures yield no mycobacteria, discontinue anti-TB therapy unless significant TB risk factors persist. 1
Monitoring and Follow-Up
Bacteriologic evaluation is often limited by difficulty obtaining follow-up specimens in extrapulmonary disease. 1 Response to treatment is judged primarily on clinical and radiographic findings. 1
Affected lymph nodes may enlarge and new nodes can appear during or after therapy without evidence of bacteriological relapse. 1 This paradoxical response does not necessarily indicate treatment failure.
Special Population: HIV-Infected Adults
For HIV-infected persons with disseminated MAC disease presenting as lymphadenitis (particularly immune reconstitution syndrome): 1
- Clarithromycin 1,000 mg daily OR Azithromycin 250 mg daily
- Plus Ethambutol 15 mg/kg daily
- With or without Rifabutin 150-350 mg daily
Therapy can be discontinued with resolution of symptoms and reconstitution of cell-mediated immune function. 1