What is the treatment for a Bartholin gland infection?

Treatment of Bartholin Gland Infection

For Bartholin gland infections with cellulitis or systemic signs, prescribe antibiotics covering gram-positive, gram-negative, aerobic and anaerobic bacteria—specifically Metronidazole, Ciprofloxacin, Levofloxacin, or Ceftriaxone—combined with surgical drainage for abscesses larger than 2 cm. 1

When Antibiotics Are Indicated

Antibiotic therapy is required when:

• Signs of cellulitis are present (erythema, warmth, swelling extending beyond the gland) 1
• Systemic infection signs exist (fever, elevated white blood cell count, malaise) 1
• Extensive inflammation involves surrounding tissues 1

For simple, non-infected Bartholin duct cysts without these features, antibiotics are not necessary and expectant management is appropriate 2.

Recommended Antibiotic Regimens

First-Line Options for Perineal Infections with Cellulitis:

• Metronidazole (covers anaerobes) 1
• Ciprofloxacin (covers gram-negatives including coliforms) 1
• Levofloxacin (broad gram-negative coverage) 1
• Ceftriaxone (broad-spectrum coverage) 1

Alternative Broad-Spectrum Option:

• Co-amoxiclav (amoxicillin-clavulanate) is suitable for empirical treatment given the polymicrobial nature of these infections, which commonly involve coliforms and mixed aerobic/anaerobic organisms 3

The microbiology of Bartholin abscesses typically involves opportunistic organisms, with coliforms being the most common pathogens, and polymicrobial infections are frequent 3. Notably, gonorrhea and chlamydia are rarely isolated in contemporary studies 3.

Surgical Management

Drainage is essential for infected cysts or abscesses larger than 2 cm, as they do not resolve spontaneously and medical management alone is insufficient 2.

Surgical options include:

• Word catheter placement (most common in emergency/office settings) 4, 2
• Marsupialization (creates permanent drainage tract) 5, 2
• Incision and drainage (immediate relief but higher recurrence) 5, 4
• CO2 laser or silver nitrate application (alternative techniques) 5, 2

Recurrence rates range from 2-25% across all surgical techniques, making definitive drainage procedures preferable to simple incision and drainage 5.

Treatment Algorithm

1. Assess for infection severity: Look for cellulitis (erythema extending into labia minora), fluctuance, fever, or systemic symptoms 1

2. If abscess >2 cm or infected: Perform surgical drainage AND initiate antibiotics 1, 2

3. Antibiotic selection:

   • Start empiric therapy with one of: Metronidazole, Ciprofloxacin, Levofloxacin, or Ceftriaxone 1
   • Consider co-amoxiclav for polymicrobial coverage 3
   • Adjust based on culture results if obtained 3

4. If <2 cm and non-infected: Expectant management with comfort measures (sitz baths, NSAIDs) 2

Important Caveats

• Flucloxacillin monotherapy, while historically common, provides inadequate coverage for the polymicrobial and gram-negative organisms typically involved 3
• Culture results take days, so empiric broad-spectrum coverage is essential initially 3
• In postmenopausal women, biopsy should be considered to rule out malignancy 5
• Sexually transmitted infections (gonorrhea, chlamydia) are uncommon causes in most populations but should be considered in high-risk patients 3
• Drug-resistant organisms including PRSP (penicillin-resistant Streptococcus pneumoniae) and BLNAR (beta-lactamase-nonproducing ampicillin-resistant Haemophilus influenzae) have been reported, requiring broader spectrum agents like cefteram or ceftriaxone 6