Pediatric Acute Suppurative Cervical Lymphadenitis: A Condition Ripe for Improved Health Care Value

A 2-year-old male with left-sided neck swelling was diagnosed with acute suppurative cervical lymphadenitis (ASCL) by his primary care provider and treated with 2 weeks of amoxicillin. Despite compliance, there was no change in size of the swelling, and he remained without signs of systemic toxicity. An ultrasonogram showed a 3.3-cm cervical lymph node with central necrosis verses abscess formation, and he was referred for otolaryngology evaluation. However, he presented to the emergency department due to enlargement of his neck mass since stopping antibiotics.In the emergency department, his physical examination was notable for a large, mildly tender cervical lymph node without erythema or warmth. He was well-appearing and afebrile and had a normal heart rate. A computed tomography (CT) scan of the head/neck revealed a 1.3 × 2.0 × 3.0-cm rim-enhancing abscess. Laboratory evaluation showed a normal white blood cell count and C-reactive protein (CRP) of 0.3 mg/dL.The patient was admitted for intravenous (IV) antibiotics, given the potential for outpatient treatment failure, and for ear, nose, and throat evaluation in the morning with possible surgical intervention. He was given IV clindamycin, and an otolaryngologist performed incision and drainage the next day. A Penrose drain was placed, and the patient was observed overnight on IV antibiotics. The following morning, the drain was removed, and the patient was discharged with a 10-day course of oral clindamycin. Abscess culture did not grow any organisms.ASCL is a common pediatric condition that occasionally requires inpatient and operative management, with thousands of children hospitalized each year with cervical lymphadenitis.1 Management variability remains due to lack of evidence-based guidelines. This article highlights decisions in the management of this child with ASCL and their implications on health care value.Predicting the need for surgical intervention can be challenging. Physical examination findings like local erythema, fluctuation, and younger age have been found to predict operative management.2,3 Additionally, whereas small abscesses (<22 mm) have been shown to respond to antibiotics, larger abscesses are more likely to require surgical drainage.3,4 Other studies have found no predictive factors for surgical intervention and no difference in time to symptom resolution or normalization of laboratory results when surgical drainage was performed,5,6 and children undergoing operative management often experience prolonged hospitalization.2 Many children with ASCL requiring surgical management are hospitalized, although there is little evidence supporting this practice. Providers may consider outpatient operative management in clinically stable children who are tolerating oral intake. Our patient may have been a candidate for outpatient surgical management given his stable presentation and established follow-up with otolaryngology.Children with surgically managed ASCL are often observed for at least 48 hours with IV antibiotics and daily CRP, and the average length of stay is 3 to 5 days;7 however, evidence supporting this practice is lacking. Studies examining length of stay for patients with ASCL found it is influenced by age, causative organism, imaging modalities used, abscess location, preadmission antibiotic usage, and prolonged time to surgery, with older children undergoing earlier surgical intervention and having shorter length of stay.8Length of stay is further impacted by IV antibiotics and lab monitoring. Expert guidance regarding IV antibiotic duration varies, but many recommend 2 to 3 days of IV antibiotics for patients with systemic features, with transition to oral therapy after adequate clinical response, although IV antibiotic duration in children with ASCL varies widely.7,9 Given complications and costs associated with IV antibiotic use, clinicians should consider earlier transition to oral antibiotics and discharge in stable children.9,10 The patient above was discharged less than 24 hours after surgery, increasing the value of his care.Serial CRP measurement has become routine for some hospitalized patients,11,12 but the usefulness of such measurements remains unclear. CRP may be helpful in severe systemic illness, unclear clinical improvement, or unexpected clinical worsening.12 For example, CRP level has been instrumental in risk stratifying infants for occult bacterial infections.13 Although studies describing the role of CRP in ASCL are lacking, the utility of trending CRP in a condition where clinical improvement is apparent through physical examination and vital sign measurement is questionable. Similarly, procalcitonin has become routine measurement for some hospitalized patients. Although procalcitonin may be helpful in predicting bacterial infections, little data exist for its use in ASCL.14 Providers caring for children with ASCL should avoid routine trending of CRP, which may increase costs and prolong hospital stay.Children admitted with ASCL are commonly managed with otolaryngology consultation or within a surgical comanagement model. Infectious disease consultation may also be considered in cases with diagnostic uncertainty, lack of expected improvement, or unusual organisms. Consultants bring valuable guidance to patient care but can present challenges that impact health care value.15 Providers may acquiesce to lower value care recommendations out of a desire to not offend another provider, especially in cases of comanagement where no primary care team exists. Providers of all specialties should question management that is habit-driven rather than evidence-based. Institutions can improve the health care value of comanagement models for ASCL and other conditions by following recently published best practices guidelines regarding surgical comanagement.16ASCL is a diagnosis with many decision points, during which utilizing shared decision-making has the potential to increase health care value by ensuring caregiver values and risk tolerance are considered.17 There are many points both prior to and during hospitalization at which shared decision-making can improve health care value in this population. For example, providers may discuss broadening oral antibiotic coverage and outpatient observation rather than admission when appropriate. Timing of surgical intervention and emergency department presentation may also be discussed in children who are not ill-appearing and are tolerating oral intake, as once children are hospitalized, they may be kept from eating or drinking for multiple nights while awaiting potential surgical intervention the following day.Although some variability exists in empirical antibiotic choice in this population, the American Academy of Pediatrics RedBook recommends cephalexin or amoxicillin-clavulanate in most cases, or clindamycin if Methicillin-resistant Staphylococcus aureus (MRSA) is suspected.18 Prior studies have shown Methicillin-sensitive Staphylococcus aureus (MSSA) and Streptococcus pyogenes to be the most common organisms in pediatric ASCL, and ampicillin-sulbactam and beta-lactam therapy (predominantly flucloxacillin or first-generation cephalosporins) were common antibiotics prescribed for ASCL.7,19 However, a retrospective study in the midwestern United States found clindamycin to be a commonly prescribed antibiotic.20 Literature describing MRSA infection has shown varying prevalence, with some reporting as high as 29% of cultures21 and others reporting as low as 6%,7 highlighting the importance of knowing community microbiology trends when deciding empirical coverage. The patient above may have benefited from initial treatment with and/or escalation to a first-generation cephalosporin or addition of a beta-lactamase inhibitor after little improvement was seen, as these antibiotics have improved coverage for MSSA than amoxicillin.18 Additionally, escalation to clindamycin may have been unnecessary given low community MRSA rates, lack of evidence of a resistant organism, lack of systemic illness, and negative abscess culture.Evaluation of ASCL often involves imaging by ultrasonogram or CT. Case series data show no difference in length of stay in patients with surgically managed ASCL initially imaged by ultrasonogram vs CT,22 and retrospective data found patients with earlier imaging have increased odds of having multiple imaging studies, surgical drainage, and 30-day readmission for lymphadenitis.1 The benefits of ultrasonogram include avoidance of radiation exposure and potential sedation, and ultrasonogram has comparable sensitivity in determining the need for surgical drainage.23 Additionally, utilizing ultrasonogram as the primary diagnostic imaging in children with ASCL can decrease CT scan utilization without impacting rates of operative management and treatment failure.24 In our case, repeat ultrasonograms may have obviated the need for CT.Our patient was hospitalized for IV antibiotics and surgical intervention, although these decisions warrant reconsideration. Indications for hospitalization in children with ASCL may include respiratory distress or need for IV antibiotics, including severe systemic illness, oral intolerance, or antimicrobial resistance. Yet, children are occasionally started on IV antibiotics without meeting these criteria. Younger children and infants may be assumed to need IV antibiotics because of poor oral absorption;25 however, there is literature supporting the efficacy of oral antibiotics in younger infants.26,27 Additionally, treatment failure of oral antibiotics is typically described as lack of improvement or worsening at least 48 hours after treatment initiation, although there is no universal definition.28 Furthermore, failing 1 oral antibiotic may not necessitate IV antibiotics, as well-appearing children could transition to an oral antibiotic with broader coverage and be observed as outpatients. Providers should ensure true antibiotic failure has occurred prior to adjusting antibiotics in well-appearing children.This case highlights areas for improvement in the care of children with ASCL, a summary of which is found in Table 1. Providers caring for these children should strive for evidence-based care, particularly within surgical shared management models, and to engage in shared decision-making in areas of clinical equipoise. Further research directions may include studies describing practice variation, noninferiority studies for oral vs IV antibiotics, inpatient verses outpatient management, and quality improvement initiatives to decrease length of stay, CT scan utilization, unnecessary lab monitoring, and IV antibiotic duration.