Factors Associated with Surgical Intervention in Pediatric Cervical Lymphadenitis: A Cohort Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors, I have minor comments that will improve your manuscript.

Line 27&28: Please write the first alphabet of Methicillin and Aureus in small letters. Moreover, in line 27, it is methicillin-resistant, not resistance.

Line 32: "was found to be associated", not "is associated".

Line 40&46: "Bacterial inoculation" is not an appropriate term.

Line 56-59: If the factors are already reported, what is your study's importance?

Line 161&162: Please write the first alphabet of MRSA and MSSA in small letters except Staphylococcus, and make the scientific name in italics. 

Table 2: Italicize the H. influenzae italic. Also, write the full GAS abbreviation in the footnote or its complete form in the table. 

Subsections 3.7 and 3.8 have the exact text. Please delete the 3.8 subsections.

 

Author Response

Reviewer 1:

Dear authors, I have minor comments that will improve your manuscript.

We thank the reviewer.

Line 27&28: Please write the first alphabet of Methicillin and Aureus in small letters. Moreover, in line 27, it is methicillin-resistant, not resistance.

Done.

Line 32: "was found to be associated", not "is associated".

Done.

Line 40&46: "Bacterial inoculation" is not an appropriate term.

Done. The setnences now reads: “Lymph node suppuration may occur due to bacterial infiltration  of lymphatic tissue, resulting in cervical lymphadenitis.”

“ Bacterial invasion of lymphatic tissue within the neck…”

Line 56-59: If the factors are already reported, what is your study's importance?

Our study examines a large cohort of 201 pediatric patients, contributing to the existing understanding of cervical lymphadenitis management. While previous research has identified factors associated with surgical drainage, we have conducted extensive research aimed at building on these findings by also assessing the role of antibiotic treatment and its outcomes. Additionally, our study takes a comprehensive approach, considering both surgical and non-surgical management strategies. This perspective may be particularly useful for primary care physicians, who are often the first to evaluate and treat these patients. By identifying key clinical factors early, we hope to support timely decision-making and optimize patient care.

Line 161&162: Please write the first alphabet of MRSA and MSSA in small letters except Staphylococcus, and make the scientific name in italics. 

Done.

Table 2: Italicize the H. influenzae italic. Also, write the full GAS abbreviation in the footnote or its complete form in the table. 

Done.

Subsections 3.7 and 3.8 have the exact text. Please delete the 3.8 subsections.

Done.

 

We appreciate the reviewers insightful comments, which have helped us improve the quality of our manuscript. We hope that our revisions address all concerns satisfactorily and look forward to your further feedback.

Reviewer 2 Report

Comments and Suggestions for Authors

I am grateful for the opportunity to review your valuable article.

This is a retrospective study of the factors related to the indication for incisional drainage in superficial suppurative lymphadenitis.

The conclusions obtained are almost similar to those of previous reports and are not considered to be particularly novel.

However, this is a study of about 200 patients at a single institution, and we believe it has some clinical value.

There are several points that need to be reconsidered and are mentioned below.

It is not good that not much consideration has been given to the treatment effect determination as an outcome in this study, except for the length of hospital stay, which is likely to be the most important. Data on the duration of antimicrobial administration should be presented and a discussion of the duration of antimicrobial administration should be presented. The type of antimicrobials used should also be presented. In our study, the more cases of superficial abscess-forming neck infections that required puncture, the longer the duration of treatment. We interpret this as a tendency for puncture to be performed in severe cases. On the other hand, in cases of deep abscess-forming neck infections, the duration of antimicrobial therapy was shorter in the punctured cases than in the non-punctured cases.

The high prevalence of Staphylococcus aureus as the organism responsible for superficial suppurative lymphadenitis is consistent with many previous reports. On the other hand, the proportion of methicillin-resistant Staphylococcus aureus (MRSA) bacteria in Staphylococcus aureus in this paper appears to be very high (12/32). In our study, the frequency of MRSA in Staphylococcus aureus detected in superficial abscess-forming neck abscesses was less than 10% (2/29). It is better to discuss about this point.

Table 2 lists three cases of disease complications and four cases of complications in puncture drainage. A detailed description of these should be added. If necessary, a discussion of them should also be added.

Author Response

Reviewer 2:

I am grateful for the opportunity to review your valuable article.

We thank the reviewer for their valuable comments. We have made extensive efforts to address the concerns raised, aiming to enhance the evaluation and treatment of the disease and better characterize its features.

This is a retrospective study of the factors related to the indication for incisional drainage in superficial suppurative lymphadenitis. The conclusions obtained are almost similar to those of previous reports and are not considered to be particularly novel.However, this is a study of about 200 patients at a single institution, and we believe it has some clinical value.

We appreciate the reviewer’s thoughtful assessment. While some findings align with previous reports, our study builds on existing knowledge by analyzing a large cohort and evaluating antibiotic treatment outcomes. By integrating both surgical and non-surgical management, we offer practical insights, particularly for primary care physicians, to support more informed treatment decisions.

There are several points that need to be reconsidered and are mentioned below. It is not good that not much consideration has been given to the treatment effect determination as an outcome in this study, except for the length of hospital stay, which is likely to be the most important. Data on the duration of antimicrobial administration should be presented and a discussion of the duration of antimicrobial administration should be presented. The type of antimicrobials used should also be presented.

We thank the reviewer for their valuable insights. We have made extensive efforts to address additional outcomes of the study. Data on the duration and type of antimicrobial treatment were collected and are presented in Table 4 and the Results section. The revised paragraph now reads: “Among the 201 pediatric patients with cervical lymphadenitis, 94.5% received antibiotic treatment. (Table 4) The use of antibiotics was significantly higher in the surgical drainage group compared to the conservative treatment group (98.9% vs. 91.2%, p=0.025). Augmentin was the most frequently prescribed antibiotic in both groups, with no significant difference in its use (p=0.57). However, cephalosporins (1st/2nd generation) and clindamycin were used more often in patients who required surgical drainage compared to those managed conservatively (p=0.0003 and p=0.02, respectively), suggesting an association with more severe or refractory infections.

Treatment duration was also significantly longer in the surgical drainage group, with an average of 14.8 ± 6.2 days compared to 11.0 ± 3.4 days in the conservative group (p<0.001). Patients requiring surgical intervention were more likely to receive prolonged antibiotic courses, with 27.9% receiving treatment for more than 14 days, compared to only 5.8% in the conservative group (p<0.001). These findings highlight the increased treatment burden in patients with more severe infections requiring surgical management.”

 In our study, the more cases of superficial abscess-forming neck infections that required puncture, the longer the duration of treatment. We interpret this as a tendency for puncture to be performed in severe cases. On the other hand, in cases of deep abscess-forming neck infections, the duration of antimicrobial therapy was shorter in the punctured cases than in the non-punctured cases.

We have discussed our findings in the Discussion section: “Our findings indicate that surgical drainage in pediatric cervical lymphadenitis is associated with increased antibiotic use, particularly first- and second-generation cephalosporins and clindamycin, as well as prolonged treatment durations. This suggests that surgical intervention is more commonly performed in severe or refractory cases, necessitating broader-spectrum antibiotics and extended therapy. Additionally, the relationship between abscess depth, drainage, and treatment duration warrants further consideration. Similar to previous reports, we observed that superficial abscesses requiring drainage were associated with longer antibiotic courses, likely reflecting more severe infections or a delayed response to treatment. In contrast, studies have suggested that in deep abscesses, timely and adequate drainage may facilitate faster resolution, potentially reducing the need for prolonged antibiotic therapy. These findings emphasize the importance of early risk stratification and optimized management strategies in pediatric cervical lymphadenitis.”

The high prevalence of Staphylococcus aureus as the organism responsible for superficial suppurative lymphadenitis is consistent with many previous reports. On the other hand, the proportion of methicillin-resistant Staphylococcus aureus (MRSA) bacteria in Staphylococcus aureus in this paper appears to be very high (12/32). In our study, the frequency of MRSA in Staphylococcus aureus detected in superficial abscess-forming neck abscesses was less than 10% (2/29). It is better to discuss about this point.

We have added a brief discussion on this issue. The revised paragraph in the Discussion section now reads: “ The predominance of Staphylococcus aureus in superficial suppurative lymphadenitis aligns with previous studies; however, the proportion of MRSA reported in some studies appears notably lower than in our cohort.^16,17 In our study, MRSA accounted for more than 37% of S. aureus isolates in abscess-forming infections requiring drainage, suggesting potential regional or institutional differences in resistance patterns that warrant further investigation.”

Table 2 lists three cases of disease complications and four cases of complications in puncture drainage. A detailed description of these should be added. If necessary, a discussion of them should also be added.

We have re-evaluated and re-entered all cases of complications to provide more comprehensive descriptions. The revised paragraph in the Results section now reads: “Disease-related complications were documented in three cases, including airway obstruction, jugular vein thrombosis, and sepsis. In contrast, drainage-related complications were reported in four cases, involving marginal mandibular nerve injury, vascular complications, and wound dehiscence. Notably, all complications were temporary and resolved over time without long-term consequences.” 

 

We appreciate the reviewers insightful comments, which have helped us improve the quality of our manuscript. We hope that our revisions address all concerns satisfactorily and look forward to your further feedback.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

I am grateful for the opportunity to review your revised article.

Although you have adequately answered some of the questions I submitted last time, there are a few that are unclear, and         I would like to review them.

Augmentin is a trade name and should be changed to a generic name.

Regarding antimicrobial therapy, the distinction between transvenous and orally administered therapy is ambiguous. You need to outline your institution's antimicrobial therapy policy. For example, you need to mention the criteria for transitioning from intravenous antimicrobial therapy to oral antimicrobial therapy. I believe that it is necessary to describe not only the duration of total antimicrobial therapy but also the duration of transvenous antimicrobial therapy. I thought it would be good to discuss whether puncture drainage could potentially shorten transvenous antimicrobial therapy.

MRSA (methicillin-resistant Staphylococcus aureus) was detected in 12 cases, but no anti-MRSA antibacterial agents were used in the table 4 of antibacterial agents used. Does this mean that treatment was successful with non-susceptible antimicrobial therapy? I believe that puncture drainage has two significant aspects. The first is the direct treatment by drainage of the pus. The second is the identification of the causative organism, which allows targeted antimicrobial therapy. I think that the latter perspective is lacking in the revised version.

Author Response

We thank the reviewer for his constructive remarks, and we are pleased to answer the questions regarding our recent submission of the manuscript, amh-3524977‏‏, titled “Factors associated with Surgical Intervention in Pediatric Cervical Lymphadenitis: A cohort study”.

Reviewer 2:

I am grateful for the opportunity to review your revised article. Although you have adequately answered some of the questions I submitted last time, there are a few that are unclear, and I would like to review them.

We Thank the reveiwer for the thorough review and valuable feedback. 

Augmentin is a trade name and should be changed to a generic name.

Done. We acknowledge the use of a trade name and have corrected “Augmentin” to its generic name, Amoxicillin-Clavulanate (AMOXI-CLAV). 

Regarding antimicrobial therapy, the distinction between transvenous and orally administered therapy is ambiguous. You need to outline your institution's antimicrobial therapy policy. For example, you need to mention the criteria for transitioning from intravenous antimicrobial therapy to oral antimicrobial therapy. I believe that it is necessary to describe not only the duration of total antimicrobial therapy but also the duration of transvenous antimicrobial therapy. I thought it would be good to discuss whether puncture drainage could potentially shorten transvenous antimicrobial therapy.

We thank the reveiwer for this important comment. Regarding antimicrobial therapy, intravenous treatment was administered for an average of three days. Transition to oral therapy was generally performed upon clinical improvement and, in most cases, after receiving culture results, if available.  The revised paragraph in the Methods section now reads: “We collected comprehensive data on antibiotic treatment in both groups, including its duration. Regarding antimicrobial therapy, intravenous treatment was administered for an average of three days. Transition to oral therapy was typically made upon clinical improvement and, in most cases, after receiving culture results, if available.”

MRSA (methicillin-resistant Staphylococcus aureus) was detected in 12 cases, but no anti-MRSA antibacterial agents were used in the table 4 of antibacterial agents used. Does this mean that treatment was successful with non-susceptible antimicrobial therapy?

Table 4 presents the different treatment options received by children in both the traditional and drainage groups. Regarding the 12 children in whom MRSA was detected, Clindamycin and Trimethoprim-Sulfamethoxazole (Resprim) are both effective treatment options for MRSA and are listed in the table.

I believe that puncture drainage has two significant aspects. The first is the direct treatment by drainage of the pus. The second is the identification of the causative organism, which allows targeted antimicrobial therapy. I think that the latter perspective is lacking in the revised version.

We thank the reviewer for this important comment and have addressed this perspective in the Discussion section. The revised sentence now reads: “Beyond its role in direct pus evacuation, puncture drainage serves another critical function: the identification of the causative organism, which enables targeted antimicrobial therapy. This aspect is essential for optimizing treatment decisions, particularly in the context of antibiotic resistance and ensuring appropriate pathogen-directed therapy.”

We appreciate the reviewer insightful comments, which have helped us improve the quality of our manuscript. We hope that our revisions address all concerns satisfactorily and look forward to your further feedback.