Paediatric Pathways

Cervical lymphadenitis / Lymph node abscess pathway for children presenting to hospital

DIFFERENTIALS

Acute presentation of unilateral, red, hot, tender neck lump. Often associated with fever.

Differentials include:

  1. Infection
    • Bacterial lymphadenitis / LN abscess (more common in children <6 years of age)
    • Bartonella (Cat scratch)
    • Toxoplasmosis
    • TB / non-tuberculous mycobacteria (usually painless, non-tender)
    • Infected congenital cyst such as branchial cyst or lymphangioma
    • Consider mumps if parotid swelling
  2. Kawasaki disease
  3. Sternocleidomastoid tumour in neonates
  4. Malignancy (lymphoma, leukaemia)
  5. Severe eczema is the commonest cause of generalised lymphadenopathy

 

# RED FLAGS:

  • Stertor or stridor suggesting airway obstruction
  • Difficulty swallowing/drooling
  • Muffled speech
  • Torticollis (can occur in minor infections but potential sign of retropharyngeal infection)
  • Severe respiratory distress
  • Haemodynamic instability / sepsis (may require urgent source control)

URGENT senior review and ENT input

INVESTIGATIONS

Evaluate severity of infection:
MILD = systemically well
MODERATE = previous antibiotic failure, systemically unwell or clinical signs suggestive of LN abscess (fluctuant mass).
SEVERE = presence of any red flags

If MILD infection, no investigations required.
If MODERATE / SEVERE infection, for FBC, CRP and blood culture +- throat swab
Consider USS if clinical signs suggestive of LN abscess. Urgent imaging (USS neck) if severe infection#. If retropharyngeal infection suspected, consider urgent CT neck.2
In severe cases, ensure airway secure before imaging.

MANAGEMENT

MILD infection – manage with oral antibiotics as per local / national guidelines.

Choice of oral Abx as per local / national guidelines
Total duration of treatment = 7 days
Provide verbal and written safety netting information

In MILD infection, consider IVAbx if:

  • Oral Abx not tolerated/absorbed
  • No improvement despite ≥48 hours of adequate oral Abx (check dose and adherence). Incision and drainage may be required – consider USS.
  • Significant immunosuppression

Choice of antibiotic as per local empirical antibiotic guidelines

MANAGEMENT

MODERATE infection – initially manage with IVAbx as per local empirical antibiotic guidelines. If clinical deterioration despite 24 hours IVAbx or persisting fever/no clinical improvement despite 48 hours IVAbx, arrange urgent USS. If collection, for ENT review and consider incision and drainage. Conservative treatment can be considered in children with small collections (<2.2cm) if no red flag features present.1,2
If development of red flags, for urgent ENT review and consider urgent CT neck.2 Ensure airway secure before imaging.

Consider ambulation4 on IVAbx from ED / assessment unit (admission avoidance) unless:

Ensure robust clinical governance systems and documentation in place for children being ambulated
Daily review required and provide verbal and written safety netting information
IV to oral switch when:

  • Clinically improving +- improving inflammatory markers
  • Apyrexial
  • If source control (I+D), then early IV to oral switch recommended.
  • Choice of oral Abx as per local / national guidelines. Total duration of treatment (IV+oral )= 7 days

If clinically deteriorating or remains pyrexial despite antibiotics, consider:

  • Deep seated infection requiring source control; ENT review +- imaging (USS)
  • Resistant organism – check risk factors and microbiology results
  • Non-infective pathology or unusual infection (consider differentials)
  • Seek ID/micro advice if complex infection

MANAGEMENT

SEVERE infection – start IVAbx as per local / national guidelines

  • Urgent ENT review and consideration of source control (operative management)
  • If airway is compromised by swelling, consider emergency measures to secure it
  • If evidence of toxin mediated disease, consider adding an antitoxin antibiotic (i.e. clindamycin) and lower threshold for urgent drainage (source control).

The development of this pathway involved a systematic review of the literature, collaborative development of the pathway with relevant national groups followed by formal national consultation. For more information, click here

REFERENCES
  1. Luu TM, Chevalier I, Gauthier M et al. Acute adenitis in children: clinical course and factors predictive of surgical drainage. J Paediatr Child Health 2005; 41: 273-7.
  2. Georget E, Gauthier A, Brugel L et al. Acute cervical lymphadenitis and infections of the retropharyngeal and parapharyngeal spaces in children. BMC Ear Nose Throat Disord 2014; 14: 8.
  3. McMullan BJ, Andresen D, Blyth CC et al. Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines. Lancet Infect Dis 2016; 16: e139-52.
  4. Patel S, Abrahamson E, Goldring S et al. Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement. J Antimicrob Chemother 2015; 70: 360-73.