What is the treatment for lymphadenitis?

Treatment of Lymphadenitis

Primary Treatment Approach Based on Etiology

The treatment of lymphadenitis fundamentally depends on the causative organism: non-tuberculous mycobacterial (NTM) lymphadenitis requires complete excisional surgery without chemotherapy as first-line treatment, while acute bacterial lymphadenitis is treated with appropriate antibiotic therapy targeting Staphylococcus aureus and Streptococcus pyogenes. 1, 2

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Non-Tuberculous Mycobacterial (NTM) Lymphadenitis

Surgical Management (First-Line)

• Complete excisional surgery without chemotherapy achieves approximately 95% success rate and is the definitive treatment for children with NTM cervical lymphadenitis. 3, 1
• This approach is particularly effective for disease caused by MAC (Mycobacterium avium complex) and M. scrofulaceum. 3

Critical Pitfalls to Avoid

• Never perform incisional biopsy alone or simple drainage—this leads to persistent disease, chronic sinus tract formation, and ongoing drainage in the majority of cases. 3, 2
• Avoid anti-TB drugs without macrolides, as this approach consistently results in treatment failure. 3, 2

Alternative Medical Management

• For recurrent disease after initial surgery, perform a second surgical excision. 3
• When surgical risk is prohibitively high (e.g., preauricular nodes with facial nerve involvement risk), use a clarithromycin-based multidrug regimen similar to that used for pulmonary MAC disease. 3, 1, 2
• This medical approach has limited experience but is supported by clarithromycin's proven activity against MAC in other clinical settings. 3

Special Consideration for TB Risk

• When a child with granulomatous lymphadenitis has a strongly positive PPD (≥15 mm) or TB risk factors (foreign-born, positive family history), initiate anti-TB therapy while awaiting culture results. 3, 2
• Discontinue anti-TB therapy if cultures yield no mycobacteria and no significant TB risk factors exist. 3, 2

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Acute Bacterial Lymphadenitis

Uncomplicated Disease (No Abscess Formation)

First-line antibiotic options:

• Clindamycin 300-450 mg orally three times daily 2
• Amoxicillin-clavulanate 875/125 mg orally twice daily 2
• Flucloxacillin or first-generation cephalosporins (particularly effective in low MRSA-prevalence settings) 4

Recent evidence from 2025 demonstrates that oral cloxacillin is non-inferior to amoxicillin-clavulanic acid for uncomplicated pediatric bacterial lymphadenitis, with mean defervescence times of 5.74 days versus 5.92 days respectively. 5 In settings with low methicillin-resistant S. aureus prevalence (such as Europe and Australasia), narrow-spectrum beta-lactam therapy like flucloxacillin achieves excellent outcomes with low relapse rates. 4

• Duration: 7-14 days for staphylococcal or streptococcal infections. 2
• Most cases are caused by methicillin-susceptible S. aureus (49%) and Group A Streptococcus (43%), with MRSA representing only 6% of culture-positive cases in low-prevalence areas. 4

Complicated/Suppurative Disease (With Abscess)

Management algorithm:

• Obtain early imaging to confirm abscess formation. 4
• Hospitalize patients who are immunocompromised, neutropenic, or have systemic complications. 2
• Initiate empiric therapy with vancomycin plus antipseudomonal antibiotics for high-risk patients. 2
• Clindamycin use is more frequent in complicated disease, though optimal antibiotic choice remains under investigation. 4

Surgical intervention:

• Perform abscess drainage (aspiration or surgical) promptly. 2, 6
• Obtain pathogen isolation and tissue biopsy to ensure accurate diagnosis and guide antibiotic selection. 6
• Infectious diseases consultation is recommended for complicated cases. 4

Predictors Requiring Surgical Drainage

• Immunocompromised host status 6
• Male sex 6
• Prior inadequate antibiotic treatment 6
• Presence of fluctuation on examination 6

Complications to Monitor

• Cellulitis of neck soft tissue 6
• Supraglottic swelling 6
• Internal jugular vein thrombosis 6
• Sepsis 6

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Specific Pathogen-Directed Treatment

Cat Scratch Disease (Bartonella henselae)

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

Borrelial Lymphocytoma (Lyme Disease)

• Oral antibiotic therapy for 14 days: doxycycline, amoxicillin, or cefuroxime axetil. 1, 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

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Clinical Pearls and Common Pitfalls

When to Suspect Alternative Diagnoses

• Failure to respond to empiric antibiotics within 48-72 hours warrants diagnostic re-evaluation for alternative microbiologic causes or need for surgical intervention. 7
• Consider tuberculous lymphadenitis (TBLN) in endemic areas—it presents similarly to suppurative lymphadenitis but typically involves multiple nodes that are less painful and lack fluctuation. 6
• Consider melioidosis and actinomycosis, particularly after drainage in endemic regions. 6

Timing Considerations

• Patients with complicated disease typically present later (delayed presentation) and require longer antibiotic durations, prolonged hospital stays, and higher rates of surgical intervention compared to uncomplicated cases. 4
• Most uncomplicated bacterial lymphadenitis is self-limited and may not require treatment in all cases. 8

Culture and Diagnostic Approach

• Obtain Gram stain and culture of aspirated material when possible before initiating antibiotics. 2
• Perform tuberculin skin test (PPD) in all suspected cases to distinguish tuberculous from non-tuberculous mycobacterial lymphadenitis. 2