What is the best approach to manage lymphadenitis?

Management of Lymphadenitis

The management of lymphadenitis is determined by the causative organism: bacterial lymphadenitis requires empiric antibiotic therapy targeting S. aureus and S. pyogenes, while non-tuberculous mycobacterial (NTM) lymphadenitis is best treated with complete surgical excision. 1, 2

Initial Assessment and Diagnostic Approach

• Obtain Gram stain and culture of aspirated material from the affected lymph node to identify the causative pathogen 2
• Perform tuberculin skin test (PPD) in all suspected cases to distinguish tuberculous from non-tuberculous mycobacterial lymphadenitis 3
• Assess for specific risk factors: overlying skin changes, multiple or bilateral nodal disease, and preauricular location (high risk for facial nerve injury) 3, 4

Treatment Algorithm by Etiology

Acute Bacterial Lymphadenitis (Uncomplicated)

For early-stage suppurative lymphadenitis without abscess formation, initiate empiric antibiotic therapy with either Clindamycin 300-450 mg orally three times daily OR Amoxicillin-clavulanate 875/125 mg orally twice daily. 2

• In low methicillin-resistant S. aureus (MRSA) prevalence settings, narrow-spectrum beta-lactam monotherapy (flucloxacillin or first-generation cephalosporins) is highly effective for uncomplicated disease 5
• Continue appropriate antibiotics for 7-14 days for staphylococcal or streptococcal infections 2
• Methicillin-susceptible S. aureus (49%) and Group A Streptococcus (43%) are the predominant pathogens in culture-positive cases 5

Acute Bacterial Lymphadenitis (Complicated/Suppurative)

• For complicated disease with abscess formation, obtain early imaging and pursue prompt surgical drainage 5
• Treatment is more variable with higher rates of clindamycin use compared to uncomplicated cases 5
• Consider infectious diseases consultation to guide antibiotic therapy in complicated cases 5
• For immunocompromised or neutropenic patients, hospitalize and initiate empiric therapy with vancomycin plus antipseudomonal antibiotics 2

Non-Tuberculous Mycobacterial (NTM) Lymphadenitis

Complete excisional surgery without chemotherapy is the primary treatment for NTM cervical lymphadenitis, with a success rate of approximately 95%. 1, 2

• Never perform incisional biopsy alone or drainage alone for suspected NTM lymphadenitis, as this frequently leads to persistent disease, sinus tract formation, and chronic drainage. 1, 2, 3
• Avoid anti-TB drugs without macrolides as they lead to treatment failure 1
• For recurrent disease or when surgical risk is high (particularly preauricular location with facial nerve injury risk), use a clarithromycin-based multidrug regimen 1, 2, 3
• More aggressive management with surgical excision and antibiotics is recommended for patients with overlying skin changes and extensive nodal disease (multiple or bilateral nodes) 4

Tuberculous Lymphadenitis

• When TB is suspected, initiate anti-TB therapy immediately while awaiting culture results, especially when risk factors for TB are present 1, 2, 3
• Discontinue anti-TB therapy if cultures fail to yield mycobacteria and no significant risk factors exist 2

Borrelial Lymphocytoma (Lyme Disease)

• For patients with borrelial lymphocytoma, prescribe oral antibiotic therapy for 14 days 1
• Oral antibiotic options include doxycycline, amoxicillin, or cefuroxime axetil 1

Specific Pathogen-Directed Treatment

Cat Scratch Disease

• Azithromycin: For patients >45 kg, give 500 mg on day 1 followed by 250 mg for 4 additional days; for patients <45 kg, give 10 mg/kg on day 1 and 5 mg/kg for 4 more days 2

Tularemia

• Severe cases: Streptomycin 15 mg/kg IM every 12 hours OR gentamicin 1.5 mg/kg IV every 8 hours 2
• Mild cases: Tetracycline 500 mg orally four times daily OR doxycycline 100 mg orally twice daily 2

Bubonic Plague

• Streptomycin 15 mg/kg IM every 12 hours OR doxycycline 100 mg orally twice daily 2
• Gentamicin may substitute for streptomycin if unavailable 2

Critical Pitfalls to Avoid

• Never perform incisional biopsy or drainage alone for NTM lymphadenitis—this creates chronic fistulae and persistent disease 1, 2, 3
• Avoid using anti-TB drugs without macrolides for NTM lymphadenitis 1
• Do not use intra-articular corticosteroids during the initial treatment period 6
• Always obtain cultures before starting antibiotics when possible 3
• Recognize that preauricular location carries significant risk for facial nerve injury during excision; consider medical therapy first in this location 3

Special Considerations

• Failure to respond to empiric antibiotics within 48-72 hours should trigger diagnostic re-evaluation for alternative microbiologic diagnoses or need for surgical intervention 7
• BCG lymphadenitis does not respond to cephalexin treatment and does not hasten recovery 8
• Children with complicated disease generally present later, have prolonged length of stay, longer antibiotic durations, and higher frequency of surgical intervention compared to uncomplicated cases 5