Quick Medical Diagnosis & Treatment 2021

Lymphangitis & Lymphadenitis

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For further information, see CMDT Part 12-17: Lymphangitis & Lymphadenitis

Key Features

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Essentials of Diagnosis

Red streak from wound or cellulitis toward enlarged, tender regional lymph nodes
Chills, fever, and malaise

General Considerations

Lymphangitis and lymphadenitis are common manifestations of a bacterial infection
- Usually caused by hemolytic streptococci or Staphylococcus aureus (or both)
- Becomes invasive, generally from an infected wound, cellulitis, or abscess
Wound may be small or superficial, or an established abscess may be present
Infection may progress rapidly, often in a matter of hours

Clinical Findings

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Symptoms and Signs

Throbbing pain usually present at the site of bacterial invasion
Malaise
Anorexia
Sweating
Chills
Temperature of 38–40°C
Rapid pulse
Red streak may be definite or very faint and easily missed
Regional lymph nodes may be significantly enlarged and tender

Differential Diagnosis

Superficial thrombophlebitis
Cat-scratch fever (Bartonella henselae infection)
Acute streptococcal hemolytic gangrene
Cellulitis
Necrotizing soft tissue infection

Diagnosis

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Laboratory Tests

Leukocytosis with a left shift
Blood cultures often positive for Staphylococcus or Streptococcus

Treatment

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Medications

Analgesics
Empiric antibiotic therapy for hemolytic streptococci or S aureus (or both organisms) should always be instituted
- Cephalexin, 0.5 g orally four times daily for 7–10 days
- If high-risk for methicillin-resistant S aureus, trimethoprim-sulfamethoxazole two double strength tablets orally twice daily for 7–10 days
- Table 30–6

Table 30–6.Examples of empiric choices of antimicrobials for adult outpatient infections (in alphabetical order).

View Table||Download (.pdf)

Table 30–6. Examples of empiric choices of antimicrobials for adult outpatient infections (in alphabetical order).

Suspected Clinical Diagnosis

Likely Etiologic Agents

Medications of Choice

Alternative Medications

Acute sinusitis

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Amoxicillin-clavulanate,¹ 875 mg orally twice daily for 10 days

For patients allergic to penicillin, doxycycline, 100 mg twice daily for 10 days

Aspiration pneumonia

Mixed oropharyngeal flora, including anaerobes

Clindamycin, 300 mg orally four times daily for 10–14 days

Amoxicillin 500 mg orally three times daily for 10–14 days

Cystitis

Escherichia coli, Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus species, other gram-negative rods or enterococci

Nitrofurantoin monohydrate macrocrystals 100 mg twice daily for 5–7 days (unless pregnant); fosfomycin 3 g orally as a single dose

Cephalexin, 500 mg orally four times daily for 7 days, for uncomplicated cystitis. Due to increasing bacterial resistance, TMP-SMZ and fluoroquinolones are not recommended as first-line therapy for empiric treatment

Erysipelas, impetigo, cellulitis, ascending lymphangitis

Group A streptococcus

Penicillin V, 500 mg orally four times daily for 7–10 days

Cephalexin, 500 mg orally four times daily for 7–10 days; or azithromycin, 500 mg on day 1 and 250 mg on days 2–5

Furuncle with surrounding cellulitis

Staphylococcus aureus

Dicloxacillin, 500 mg orally four times daily for 7–10 days for MSSA. For CA-MRSA: TMP-SMZ² one double-strength tablet twice daily for 7–10 days; or clindamycin 300 mg orally three times daily for 7–10 days

Cephalexin, 500 mg orally four times daily for 7–10 days for MSSA. For CA-MRSA, doxycycline is a reasonable alternative

Gastroenteritis

Salmonella, Shigella, Campylobacter, Entamoeba histolytica

See footnote 3

Otitis media

S pneumoniae, H influenzae, M catarrhalis

Amoxicillin, 500 mg–1 g orally three times daily for 10 days

Amoxicillin-clavulanate,¹ 875 mg orally twice daily; or cefuroxime, 500 mg orally twice daily; or cefpodoxime, 200–400 mg daily; or doxycycline, 100 mg twice daily

Pelvic inflammatory disease

Neisseria gonorrhoeae, Chlamydia trachomatis, anaerobes, gram-negative rods

Ceftriaxone 250 mg intramuscularly once plus doxycycline 100 mg orally twice daily for 14 days +/– metronidazole 500 mg orally twice daily for 14 days; or cefoxitin 2 g intramuscularly once plus probenecid 1 g orally once, plus doxycycline 100 mg orally twice daily for 14 days +/– metronidazole 500 mg orally twice daily for 14 days

Pharyngitis

Group A streptococcus

Penicillin V, 500 mg orally four times daily, or amoxicillin, 500 mg–1 g orally three times daily for 10 days

For patients with history of mild penicillin allergy, cephalexin, 500 mg orally four times daily for 10 days; for patients with IgE-mediated reaction, clindamycin, 300 mg orally four times daily for 10 days; or azithromycin, 500 mg on day 1 and 250 mg on days 2–5

Pneumonia

S pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila, Chlamydophila pneumoniae

Doxycycline, 100 mg orally twice daily

Amoxicillin, 1.0 g orally three times daily plus azithromycin 500 mg orally on day 1 and 250 mg on days 2–5. A respiratory fluoroquinolone⁴ for patients at high risk for infection due to resistant pneumococci

Pyelonephritis

E coli, K pneumoniae, Proteus species, S saprophyticus

Fluoroquinolones⁵ for 7 days if prevalence of resistance among uropathogens is < 10%

TMP-SMZ,² one double-strength tablet twice daily for 7–14 days for susceptible pathogens. Oral beta-lactams are less effective than fluoroquinolones or TMP-SMZ

Urethritis, epididymitis

N gonorrhoeae, C trachomatis

Ceftriaxone, 250 mg intramuscularly once plus azithromycin (or doxycycline) for N gonorrhoeae; azithromycin 1 g orally once, or doxycycline, 100 mg orally twice daily for 7 days, for C trachomatis

Cefixime 400 mg orally once for N gonorrhoeae⁶

Syphilis

Early syphilis (primary, secondary, or latent of < 1 year’s duration)

Treponema pallidum

Benzathine penicillin G, 2.4 million units intramuscularly once

Doxycycline, 100 mg orally twice daily for 2 weeks. Ceftriaxone 1–2 g intravenously once daily for 10–14 days

Latent syphilis of > 1 year’s duration or cardiovascular syphilis

T pallidum

Benzathine penicillin G, 2.4 million units intramuscularly once a week for 3 weeks (total: 7.2 million units)

Doxycycline, 100 mg orally twice daily, for 4 weeks

Neurosyphilis

T pallidum

Aqueous penicillin G, 18–24 million units/day intravenously for 10–14 days

¹Amoxicillin-clavulante is available as a combination of amoxicillin, 250 mg, 500 mg, or 875 mg, plus 125 mg of clavulanic acid. Augmentin XR is a combination of amoxicillin 1 g and clavulanic acid 62.5 mg.

²TMP-SMZ is a fixed combination of 1 part trimethoprim and 5 parts sulfamethoxazole. Single-strength tablets: 80 mg TMP, 400 mg SMZ; double-strength tablets: 160 mg TMP, 800 mg SMZ.

³The diagnosis should be confirmed by culture before therapy. Salmonella gastroenteritis does not require therapy. For susceptible Shigella isolates, give ciprofloxacin, 500 mg orally twice daily for 5 days. For Campylobacter infection, give azithromycin, 1 g orally times one dose, or ciprofloxacin, 500 mg orally twice daily for 5 days. For E histolytica infection, give metronidazole, 750 mg orally three times daily for 5–10 days, followed by diiodohydroxyquinoline (not available in United States), 650 mg orally three times daily for 3 weeks.

⁴Fluoroquinolones with activity against S pneumoniae, including penicillin-resistant isolates, include levofloxacin (500–750 mg orally once daily), and moxifloxacin (400 mg orally once daily). Use fluoroquinolones as drug of choice if recent non-fluoroquinolone antibiotic use within 3 months or comorbidities present.

⁵Fluoroquinolones and dosages include ciprofloxacin, 500 mg orally twice daily; ofloxacin, 400 mg orally twice daily; levofloxacin, 500 mg orally daily.

⁶Test of cure recommended if ceftriaxone is not used.

CA-MRSA, community-acquired methicillin-resistant Staphylococcus aureus; MRSA, methicillin-resistant S aureus; MSSA, methicillin-sensitive S aureus; TMP-SMZ, trimethoprim-sulfamethoxazole.

Surgery

Any necrotic tissue must be debrided and loculated pus drained

Therapeutic Procedures

Elevation (when feasible) and immobilization of infected area
Heat (hot, moist compresses or heating pad)

Outcome

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Prognosis

With proper therapy and effective antibiotic therapy, control of infection is achieved in a few days
Delayed or inadequate therapy can lead to overwhelming infection with septicemia and even death

When to Admit

Infections causing lymphangitis should be treated in the hospital with intravenous antibiotics
Debridement may be required

References

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Klotz SA et al. Cat-scratch disease. Am Fam Physician. 2011 Jan 15;83(2):152–5.
[PubMed: 21243990]

Simma L et al. Ascending upper limb lymphangitis. BMJ Case Rep. 2017 Sep 28;2017.
[PubMed: 28963387]

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Lymphangitis & Lymphadenitis

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Key Features

Essentials of Diagnosis

General Considerations

Clinical Findings

Symptoms and Signs

Differential Diagnosis

Diagnosis

Laboratory Tests

Treatment

Medications

Surgery

Therapeutic Procedures

Outcome

Prognosis

When to Admit

References

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