What is the recommended treatment for pediatric lymphadenitis, including empiric antibiotics for a well‑appearing child with a localized non‑fluctuant node and for children with systemic signs or an abscess?

Treatment of Pediatric Lymphadenitis

For well-appearing children with uncomplicated acute bacterial lymphadenitis (localized, non-fluctuant node), initiate empiric oral therapy with either clindamycin or amoxicillin-clavulanate for 7-14 days, targeting Staphylococcus aureus and Group A Streptococcus. 1

Initial Assessment and Risk Stratification

Determine if the child is well-appearing versus systemically ill, and whether the node is fluctuant or non-fluctuant, as this fundamentally changes management. 1

Well-Appearing Child with Localized Non-Fluctuant Node

• Start empiric oral antibiotics immediately: clindamycin OR amoxicillin-clavulanate for 7-14 days 1
• In low MRSA-prevalence settings (such as Europe and Australasia), narrow-spectrum beta-lactam therapy (flucloxacillin or first-generation cephalosporins) is highly effective for uncomplicated disease with low relapse rates 2
• Obtain Gram stain and culture if the node becomes fluctuant or suppurative to identify the causative pathogen 1
• The most common bacterial pathogens are methicillin-susceptible S. aureus (22-49%) and Group A Streptococcus (18.8-43%) 2, 3

Child with Systemic Signs or Abscess (Complicated Disease)

• Hospitalize immediately and initiate IV antibiotics 1
• For immunocompetent children with complicated skin and soft tissue infection (cSSTI), vancomycin is recommended 4
• If the patient is stable without ongoing bacteremia, clindamycin 10-13 mg/kg/dose IV every 6-8 hours (40 mg/kg/day total) is an option if local clindamycin resistance is low (<10%), with transition to oral therapy if the strain is susceptible 4
• Linezolid is an alternative: 10 mg/kg/dose PO/IV every 8 hours for children <12 years, or 600 mg PO/IV twice daily for children ≥12 years 4
• Early surgical consultation for incision and drainage is essential 1, 3
• Clindamycin is used more frequently in complicated disease (96-100% of MSSA and MRSA isolates are susceptible) 3

Immunocompromised or Neutropenic Patients

• Hospitalize immediately and treat with empiric vancomycin plus antipseudomonal antibiotics 1
• This population requires broader coverage due to risk of resistant organisms and disseminated infection 1

Special Etiologies Requiring Specific Treatment

Nontuberculous Mycobacterial (NTM) Lymphadenitis

• Complete excisional surgery without chemotherapy is the treatment of choice, with approximately 95% success rate 1, 5
• NTM lymphadenitis typically presents in children aged 1-5 years as unilateral, non-tender cervical adenopathy (most commonly parotid or submandibular) that develops insidiously without systemic symptoms 5, 6
• Mycobacterium avium complex (MAC) accounts for approximately 80% of culture-proven NTM cases in this age group 1, 5
• Never perform incisional biopsy or drainage alone for NTM lymphadenitis, as this creates chronic fistulae and persistent disease 1
• For larger lymph nodes (≥5 cm), difficult anatomical sites (especially preauricular location with facial nerve injury risk), or recurrent disease, consider clarithromycin-based multidrug regimen instead of surgery 5, 6
• If medical therapy is chosen, clarithromycin (often combined with rifampin) for approximately 6 months shows good tolerance and compliance, with resolution in about 7 months 7

Tuberculous Lymphadenitis

• Initiate anti-TB therapy immediately while awaiting culture results, especially when risk factors for TB are present 1
• Perform tuberculin skin test (PPD) in all suspected cases to distinguish tuberculous from NTM lymphadenitis 1
• This distinction is critical because only ~10% of culture-proven mycobacterial cervical lymphadenitis in children is tuberculosis, but it fundamentally changes treatment and requires public health notification 5

Cat Scratch Disease (Bartonella henselae)

• Azithromycin is recommended: 500 mg on day 1, then 250 mg for 4 additional days (patients >45 kg) OR 10 mg/kg on day 1, then 5 mg/kg for 4 more days (patients <45 kg) 1

Tularemia

• For severe cases: streptomycin 15 mg/kg IM every 12 hours OR gentamicin 1.5 mg/kg IV every 8 hours 1

Bubonic Plague

• Streptomycin 15 mg/kg IM every 12 hours OR doxycycline 100 mg orally twice daily 1
• Note: Tetracyclines should not be used in children <8 years of age 4

Lyme Disease (Borrelial Lymphocytoma)

• Oral antibiotics for 14 days: doxycycline, amoxicillin, or cefuroxime axetil 1

Duration of Therapy

• For uncomplicated bacterial lymphadenitis: 7-14 days of oral antibiotics 1
• Median duration of discharge antibiotics after surgical drainage is 10 days 3
• For NTM lymphadenitis treated medically: approximately 6 months 7

Surgical Considerations

• Indications for surgical drainage include: fluctuant/suppurative nodes, abscess formation, or failure of antibiotic therapy 1, 3
• Only aerobic cultures should be sent routinely intraoperatively, as anaerobic (1% positive) and fungal (0% positive) cultures are rarely positive 3
• Acid-fast bacillus (AFB) cultures should be obtained when mycobacterial infection is suspected 3
• Repeat incision and drainage is rarely needed (4.5% of cases within 3 months) 3

Follow-Up and Monitoring

• Schedule reassessment within 2 weeks to evaluate for resolution, progression, or persistence 1, 8
• Return precautions for parents include: irritability or lethargy, decreased urine output, and intractable vomiting 1
• If symptoms persist beyond 2-4 weeks or the child fails to improve with supportive care, reassess for underlying conditions including malignancy, mycobacterial infection, or other chronic infections 1, 8
• If the lymph node has not completely resolved at follow-up, proceed to definitive workup 8

Critical Pitfalls to Avoid

• Never use empiric antibiotics in the absence of signs suggesting acute bacterial infection (rapid onset, fever, tenderness, overlying erythema) when evaluating persistent lymphadenopathy, as this can mask underlying malignancy or mycobacterial disease 8
• Never use anti-TB drugs without macrolides for NTM lymphadenitis, as this leads to treatment failure 1
• Always obtain cultures before starting antibiotics when possible 1
• Recognize that preauricular location carries significant facial nerve injury risk during excision, and consider medical therapy first in this location 1
• Do not delay biopsy beyond 4 weeks in persistent lymphadenopathy without clear infectious etiology 8