What is the treatment for a Bartholin gland infection?

Treatment of Bartholin Gland Infection

For Bartholin gland infections (abscesses), perform immediate surgical drainage with Word catheter or marsupialization as primary treatment, and add antibiotics only when cellulitis or systemic infection is present, using metronidazole, ciprofloxacin, levofloxacin, or ceftriaxone. 1

Surgical Management: The Primary Treatment

Surgical drainage is the cornerstone of treatment and must be performed for any infected Bartholin gland abscess. 2, 3

Preferred Surgical Techniques:

• Word catheter placement under local anesthesia is the first-line outpatient procedure 2, 4
• Marsupialization is reserved for recurrent cases but can be offered as primary management in selected situations 2
• Simple incision and drainage alone is insufficient due to unacceptably high recurrence rates 2

Alternative Surgical Options:

• Jacobi ring device placement for duct reepithelization 2
• Silver nitrate application or alcohol sclerotherapy for gland destruction 2
• Loop of plastic tubing secured to prevent expulsion (when Word catheter unavailable) 4

Antibiotic Therapy: When and What to Use

Indications for Antibiotics:

Antibiotics should be prescribed only when the following are present: 1

• Signs of cellulitis extending beyond the abscess
• Systemic infection (fever, sepsis)
• Extensive perineal inflammation

Recommended Antibiotic Regimens:

When antibiotics are indicated, choose from: 1

• Metronidazole (covers anaerobes)
• Ciprofloxacin or Levofloxacin (covers gram-negatives and some gram-positives)
• Ceftriaxone (broad-spectrum coverage)

Broad-Spectrum Alternative:

Co-amoxiclav (amoxicillin-clavulanate) is suitable for empirical treatment when polymicrobial infection is suspected, as these infections commonly involve multiple organisms including coliforms and anaerobes 5

Microbiology Considerations

The microbiology of Bartholin gland infections is important for understanding treatment failures: 5

• Polymicrobial infections are common (73.9% positive culture rate)
• Aerobic organisms predominate, with coliforms being most frequent 5
• Opportunistic organisms are the usual culprits 5
• Sexually transmitted infections (gonorrhea, chlamydia) should be considered in the differential, though they are not the most common pathogens 1, 5

Rare but Important Pathogens:

• Penicillin-resistant Streptococcus pneumoniae (PRSP) has been reported 6
• Beta-lactamase-nonproducing ampicillin-resistant Haemophilus influenzae (BLNAR) has been documented 6
• These respiratory pathogens can cause external genitalia infections and may require adjusted antibiotic selection 6

Clinical Assessment

Key Diagnostic Features:

• Tender, fluctuant mass at the vaginal introitus at 4 or 8 o'clock position 1
• Swelling, erythema, and tenderness extending into labia minora 1
• Diagnosis is primarily clinical based on physical examination 1

Assess for Complications:

• Evaluate for cellulitis beyond the abscess margin 1
• Check for systemic signs (fever, tachycardia, hypotension) 1
• Rule out severe complications like sepsis or rectovaginal fistula 2

Treatment Algorithm

1. Perform surgical drainage (Word catheter or marsupialization) for all infected abscesses >2 cm 2, 3
2. Add antibiotics only if:
   • Cellulitis present → Use ciprofloxacin, levofloxacin, ceftriaxone, or metronidazole 1
   • Systemic infection → Use broad-spectrum coverage with co-amoxiclav or combination therapy 5
3. Ensure adequate drainage device remains in place for 3-4 weeks to allow epithelialization 2, 4
4. Follow-up at 3 weeks to assess healing and remove drainage device 4

Common Pitfalls to Avoid

• Do not perform simple incision and drainage without placement of a drainage device – this leads to high recurrence rates 2
• Do not routinely prescribe antibiotics for all Bartholin abscesses – they are only needed when cellulitis or systemic infection is present 1
• Do not use flucloxacillin as monotherapy despite its common use, as polymicrobial infections require broader coverage 5
• Do not assume sexually transmitted infections are the primary cause – opportunistic organisms are more common 5