What antibiotics are used to treat lymphadenitis in children?

Antibiotic Treatment for Lymphadenitis in Children

For uncomplicated bacterial lymphadenitis in children, narrow-spectrum beta-lactam therapy with flucloxacillin or first-generation cephalosporins is the recommended first-line treatment, while complicated disease with abscess formation requires broader coverage with clindamycin or amoxicillin-clavulanate plus surgical intervention. 1, 2

Uncomplicated Bacterial Lymphadenitis

First-line antibiotic therapy:

• Flucloxacillin (cloxacillin) is as effective as amoxicillin-clavulanate and should be preferred as a narrower-spectrum agent 2
• Amoxicillin-clavulanate 45-90 mg/kg/day of amoxicillin component divided into 2-3 doses is an alternative 3, 4
• First-generation cephalosporins are also appropriate 1

Treatment duration:

• Continue antibiotics for 7-10 days 3
• Clinical improvement should occur within 48-72 hours; if not, reevaluation is necessary 3, 5
• Mean time to defervescence is approximately 5-6 days with either flucloxacillin or amoxicillin-clavulanate 2

Microbiological considerations:

• Methicillin-susceptible Staphylococcus aureus (MSSA) accounts for 49% of culture-positive cases 1
• Group A Streptococcus represents 43% of cases 1
• Methicillin-resistant Staphylococcus aureus (MRSA) is rare (6-13.7%) in low-prevalence settings 1, 6

Complicated Bacterial Lymphadenitis (with Abscess)

Surgical management is essential:

• Incision and drainage is required for abscess formation 1, 6
• Early imaging (ultrasound or CT) should be obtained to identify collections 1
• Infectious diseases consultation is recommended 1

Antibiotic selection for complicated disease:

• Clindamycin is preferred for complicated disease due to excellent coverage of both MSSA and Group A Streptococcus 1, 6
• Pediatric dosing: 30-40 mg/kg/day divided into 3-4 doses orally, or 10-13 mg/kg/dose IV every 6-8 hours (maximum 40 mg/kg/day) 7, 8
• 96% of MSSA and 100% of MRSA isolates are susceptible to clindamycin 6
• Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component in 2 doses is an alternative 3

Treatment duration for complicated disease:

• Median antibiotic duration is 10 days (range 7-11 days) 6
• Continue until clinical resolution with longer courses if residual disease persists 1
• Only 4.5% of patients require repeat drainage within 3 months 6

Penicillin-Allergic Patients

For non-anaphylactic reactions:

• First-generation cephalosporins (cephalexin) can be used 3
• Clindamycin 30-40 mg/kg/day divided into 3-4 doses is an excellent alternative 7, 8

For severe/anaphylactic reactions:

• Clindamycin is the preferred agent 7
• Provides coverage against both beta-hemolytic streptococci and MSSA/MRSA 7

Nontuberculous Mycobacterial (NTM) Lymphadenitis

This requires a completely different approach:

• Excisional surgery without chemotherapy is the recommended treatment for NTM cervical lymphadenitis 9
• Success rate with surgical excision alone is approximately 95% 9
• Incisional biopsy alone or anti-TB drugs without a macrolide should be avoided as they lead to persistent disease and sinus tract formation 9

When surgery is high-risk or for recurrent disease:

• Clarithromycin-based multidrug regimen (same as for pulmonary MAC disease) 9, 10
• Clarithromycin plus rifampin for 6-7 months shows good tolerance and compliance 10
• Median time to resolution with antibiotics alone is 6-9 months 10

Diagnostic considerations for NTM:

• Most common in children under 5 years, particularly ages 1-3 years 9, 10
• Mycobacterium avium (67%) and M. intracellulare (28%) predominate 10
• Fine needle aspiration with NTM PCR and culture should be obtained 10
• Exclude tuberculosis with PPD, chest X-ray, and appropriate testing 9

Critical Pitfalls to Avoid

Do not routinely send anaerobic, fungal, or AFB cultures for typical acute bacterial lymphadenitis:

• Only 1% of anaerobic and 2% of AFB cultures are positive in acute presentations 6
• Aerobic cultures alone are sufficient for routine bacterial lymphadenitis 6

Do not use broad-spectrum antibiotics empirically in uncomplicated disease:

• Narrow-spectrum beta-lactams (flucloxacillin) are equally effective and promote antimicrobial stewardship 1, 2

Do not delay surgical intervention in complicated disease:

• Antibiotics alone are insufficient when abscess is present 1, 6
• Prolonged antibiotic courses without drainage lead to treatment failure 1

Do not start anti-TB therapy empirically for NTM:

• Anti-TB drugs without macrolides lead to persistent disease 9
• Await culture results unless strong circumstantial evidence for tuberculosis exists 9