What is the appropriate treatment for acute cervical lymphadenitis in a 65‑year‑old woman?

Treatment of Acute Cervical Lymphadenitis in a 65-Year-Old Woman

In a 65-year-old woman with cervical lymphadenitis, antibiotics should only be prescribed if there are clear signs of bacterial infection (fever, warmth, erythema, tenderness, rapid onset), and if these signs are absent, immediate workup for malignancy is mandatory rather than empiric antibiotic treatment. 1

Critical Age-Related Consideration

• In adults over 40 years, cervical lymphadenopathy is predominantly neoplastic rather than infectious, making malignancy the primary concern that must be excluded before considering infectious etiologies 1, 2
• Over 90% of mycobacterial cervical lymphadenitis in adults is tuberculous (versus nontuberculous mycobacteria in children), fundamentally changing the diagnostic and treatment approach 3, 2

When to Prescribe Antibiotics

Only prescribe antibiotics if ALL of the following infectious signs are present: 1

• Local signs: Warmth, erythema of overlying skin, localized swelling, tenderness to palpation
• Systemic signs: Fever, tachycardia
• Temporal pattern: Mass developed within days to weeks of upper respiratory infection, dental problem, or trauma
• Rapid onset: Symptoms progressing over days rather than weeks

Antibiotic Selection (If Infection Confirmed)

If bacterial infection is confirmed, prescribe a single broad-spectrum antibiotic covering both Staphylococcus aureus and Streptococcus pyogenes: 4, 5, 6

• Clindamycin is the preferred empiric choice given high susceptibility rates (96% for MSSA, 100% for MRSA) and coverage of both primary pathogens 4
• Duration: 10 days is the typical course 4
• Reassess within 2 weeks: If the mass has not completely resolved, immediately proceed to malignancy workup 1

Red Flags Requiring Immediate Workup (NOT Antibiotics)

Do NOT prescribe empiric antibiotics if any of these features are present: 1, 7

• Mass present ≥2 weeks or uncertain duration
• Fixed, firm, or hard consistency
• Size >1.5 cm
• Ulceration of overlying skin
• Supraclavicular or posterior cervical location
• Absence of infectious signs (no fever, warmth, erythema, tenderness)
• Painless presentation
• Progressive enlargement despite observation

Mandatory Workup When Infection is Not Evident

Proceed directly to diagnostic evaluation rather than antibiotic trial: 1, 2

• Tuberculin skin test (PPD): Essential to distinguish tuberculous from nontuberculous causes 3, 2
• Chest radiograph: Exclude intrathoracic involvement or tuberculosis 2, 7
• CT with contrast or ultrasound: Characterize the adenopathy 2
• Fine-needle aspiration (FNA): For initial cytology and culture, though excisional biopsy may be needed for definitive diagnosis 2, 7

Critical Pitfalls to Avoid

• Never prescribe antibiotics without clear infectious signs in adults, as this delays malignancy diagnosis and provides false reassurance 1
• Partial resolution on antibiotics may represent infection in an underlying malignancy and still requires complete workup 1
• If antibiotics are prescribed and the mass does not completely resolve within 2 weeks, further evaluation is mandatory 1
• Do not perform incisional biopsy alone if mycobacterial infection is suspected, as this increases fistula formation risk 2

Surgical Drainage Indications

Consider surgical drainage if: 8

• Abscess formation with fluctuation
• Immunocompromised host
• Prior inadequate antibiotic treatment
• Complications such as cellulitis, sepsis, or internal jugular vein thrombosis

During drainage, obtain aerobic cultures routinely; anaerobic, fungal, and AFB cultures have very low yield unless specific risk factors are present 4