Kessous, Roy MD; Aricha-Tamir, Barak MD; Sheizaf, Boaz MD; Shteiner, Naama MD; Moran-Gilad, Jacob MD; Weintraub, Adi Y. MD
The Bartholin glands, which become active at puberty, have ducts that are narrow and therefore are prone to obstruction at their opening. Distal blockage of the duct may result in the retention of secretions with consequent formation of a cyst or abscess.1–3 The lifelong risk of developing a Bartholin cyst or abscess is approximately 2%.4
The bacteriology of Bartholin gland abscess has received little attention, perhaps because this condition is rarely a life-threatening infection and usually does not involve complex therapeutic considerations.5 Bartholin gland abscess is mainly caused by opportunistic bacteria and typical sexually transmitted pathogens are only rarely involved in its pathogenesis.6–8 Previous studies in the 1960s and 1970s of the bacteriology of Bartholin gland abscess have emphasized the significance of Neisseria gonorrhoeae and microaerophilic streptococci, which have been implicated in at least one third of cases.5,9 However, contemporary microbiological data are lacking.
Antimicrobial treatment as an adjunct to surgical treatment of Bartholin gland abscess is sometimes advised, especially in the presence of systemic symptoms.8 In addition, antimicrobial therapy for Bartholin gland abscess is considered the first-line therapy when the abscess is not ripe enough for surgical drainage and may be considered second-line therapy when there is no clinical improvement after surgical drainage or when complications develop. A variety of antimicrobials is being used for treatment of Bartholin gland abscess.1 It should be noted that the role of antimicrobials in specific complicated situations such as recurrent abscesses, abscess formation during pregnancy, or occurrence in immunocompromised patients, including human immunodeficiency virus-infected patients, is yet to be determined.
In this study, we aimed to evaluate the clinical features and microbiological characteristics of Bartholin gland abscesses in a busy regional medical center with special emphasis on specific clinical circumstances and therapeutic considerations.
MATERIALS AND METHODS
The study was conducted at the Soroka University Medical Center, the sole tertiary hospital in the southern region of Israel. The study was approved by the institutional review board (in accordance with the Declaration of Helsinki). The study population comprised all patients who were diagnosed and treated for Bartholin abscess between the years 2006 and 2011. In our medical center, patients with Bartholin abscess are not managed in the outpatient setting. Some may receive primary antimicrobial treatment but all surgical procedures are performed in an inpatient setting. All surgically or spontaneously drained abscesses are cultured. A retrospective case series study was conducted to identify and characterize patients who were diagnosed with Bartholin gland abscess (International Classification of Diseases, 9th Revision, Clinical Modification code 616.3). Data were retrieved from the patients' medical records. Data included demographic details, obstetric history, clinical details concerning the admission diagnosis including underlying medical conditions, abscess site and description, history of previous Bartholin abscesses, laboratory results (including bacterial growth from pus cultures obtained and corresponding antimicrobial susceptibility), and medical and surgical treatment. Patients with Bartholin gland cysts who were treated surgically (no pus present) were excluded from the analysis.
Data were analyzed using descriptive statistics. We also performed a comparison between patients with and without a positive culture. Statistical analysis was performed using the SPSS 17. Statistical significance was calculated using the χ2 test for categorical variables and the Student’s t test for continuous variables. Variables including age, abscess size, the use of empirical antibiotic agents, primary abscess, elevated polymorphonuclear count, and leukocytosis were analyzed independently. Those factors that were found to be clinically relevant and statistically significant were then added to a backward regression model. A multivariate logistic regression model, with backward elimination, was constructed to find independent factors that are associated with Bartholin abscess. A value of P<.05 was considered statistically significant.
Between 2006 and 2011, 219 women were admitted to the Soroka University Medical Center as a result of Bartholin gland abscess. Clinical and demographic characteristics of study patients are presented in Table 1. Patients were mostly premenopausal (approximately 95%) and for postmenopausal women, the mean time into menopause was 4.5±3.0 years. Of Bartholin gland infections, 63% were primary and 37% were recurrent events. In the recurrent group, 81% recurred ipsilaterally and the mean time for recurrence was 32±50 months (median 12 months, range 0.5–240.5 months) after the primary event. Primary antimicrobial treatment was attempted in 41 patients (18.7%), most commonly involving amoxicillin–clavulanic acid (87% of treated patients). When comparing the rate of negative cultures between patients who received primary antimicrobial treatment and those who did not, no significant difference was noted (P=.164).
Bartholin gland abscess drainage resulted in a positive culture in 126 (61.8%) of cases. Table 2 displays the bacterial taxa recovered from pus cultures of the abscesses. Nearly all cases with positive cultures were monomicrobial, whereas 10 (4.9%) of cases were polymicrobial. Escherichia coli was the single most common pathogen in positive cultures. Information regarding antibiotic susceptibility was available for 77% of positive cultures. Antimicrobial susceptibility testing is performed routinely depending on the type of bacteria and clinical specimen. Notably, 22 (22.7%) of tested isolates exhibited penicillin-resistant and three (5.2%) were extended-spectrum beta-lactamase-producing Enterobacteriaceae infection. All three cases resolved after surgical intervention. No cases of methicillin-resistant Staphylococcus aureus were detected.
Twelve of 219 patients (5.5%) were pregnant or postpartum, of whom 10 presented during the first half of pregnancy and two at the puerperium. In these women, Bartholin gland abscess drainage resulted in a positive culture in 58.3%. Mixed cultures were commonly observed in that patient group (25%), whereas E coli, group B streptococcus, Prevotella oralis, and Morganella morganii were evenly distributed among the rest of the positive cultures (8.3%).
When cases with a positive culture were compared with culture-negative ones, a positive culture was significantly associated with fever higher than 37.5°C (25% compared with 9.3%, P=.043), leukocytosis higher than 12,000 cells/mL (50.4% compared with 33.8%, P=.027), and neutrophilia higher than 85% (17.9% compared with 5.9%, P=.021). The odds of having any of these parameters among culture-positive patients as compared with culture-negative patients were significantly higher (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3–4.3, P=.003). Using a multiple logistic regression model, controlling for age and leukocytosis, the association of positive culture with fever remained significant (adjusted OR 3.95, 95% CI 1.09–14.35, P=.036).
Growth of anaerobic bacteria was significantly associated with fever as compared with other groups (62.5% in anaerobe group compared with 5.9%, 23.3%, and 40% for Gram-positive cocci, Gram-negative bacilli, and other bacterial groups, respectively; P=.019). Likewise, leukocytosis and neutrophilia were more common in the anaerobe group, although this did not reach statistical significance. Using a multiple logistic regression model, controlling for age, the association of having a fever with a positive anaerobic culture remained significant (adjusted OR 6.34, 95% CI 1.22–32.80, P=.028).
Recurrence was not significantly associated with any specific bacterial group (P=.122). Infection with E coli was significantly more common with recurrent infection (56.8%) as compared with primary infections (37%) (P=.033). Using a multiple logistic regression model controlling for age, the association of E coli with recurrent infection remained significant (adjusted OR 2.24, 95% CI 1.05–4.70, P=.037).
The key objective of the current study was to examine the clinical course of Bartholin gland abscesses in a cohort of patients treated in a busy regional medical center and specifically to determine the microbiological features of Bartholin gland abscesses. In addition, we aimed to evaluate the role of empirical antimicrobial treatment in these patients.
The etiology of Bartholin gland abscesses is known to be polymicrobial. Anaerobes, in particular Bacteroides species, have been shown in the past to be commonly isolated from such abscesses.5,7 Previous published data regarding the implicated pathogens in Bartholin gland abscesses are relatively scarce. In our study, 61.8% of the patients were culture-positive with E coli being the single most common pathogen followed by polymicrobial infections, S aureus, group B streptococcus, and Enterococcus spp. Our findings are in agreement with more recent studies by Tanaka et al6 in 2005 and Mattila et al8 in 1994 who studied 224 patients and 249 patients, respectively, with Bartholin gland abscess. Both studies found E coli to be the most common pathogen isolated.6,8 In an additional study by Bhide et al,1 34 of 46 cases of cultured Bartholin gland abscess were culture-positive with coliforms accounting for 16 (34%) of the latter group.1
Anaerobic bacteria have been implicated as the most common microorganisms isolated from Bartholin gland abscesses in several studies.5,7 Anaerobic bacteria can easily be overlooked or missed unless the specimen is properly collected, identified, and transported to the laboratory, preferably using dedicated anaerobe culture systems. Specimens must then be appropriately processed for anaerobe recovery. In our study, swabs were routinely used for collecting pus during surgical treatment or from spontaneously draining abscesses and could result in underestimation of anaerobes compared with studies performed in settings dedicated for anaerobe recovery.7
The main primary treatment for Bartholin gland abscess consists of surgical drainage with use of antibiotics as an adjunctive measure where indicated. Controversy exists regarding the role of empirical antimicrobial treatment. Antimicrobial treatment is considered the first-line therapy when the abscess is not ripe enough for surgical drainage and may be considered second-line therapy when there is no clinical improvement after surgical drainage or when complications develop. Severe complications such as sepsis, cellulitis, and necrotizing fasciitis in patients with Bartholin gland abscess have been reported.10,11 When managing a patient with Bartholin gland abscess, the attending physician should consider the risk for potential complications and the correlation between the clinical presentation and microbiological features. We have demonstrated an association between a positive culture and markers of inflammation (fever, leukocytosis, neutrophilia). Therefore, appropriate antimicrobial agents with coverage for E coli should be considered as adjunct therapy to the surgical procedure in patients with Bartholin gland abscess in the presence of systemic signs.
Sexually transmitted microorganisms such as N gonorrhoea and Chlamydia trachomatis are thought to be the initiating microorganisms in Bartholin abscesses. Bleker et al12 found four cases of N gonorrhoea and one case of C trachomatis in 56 cases of Bartholin gland abscesses. The authors concluded that the role of these pathogens is limited yet recommended a mandatory scan for sexually transmitted infections (STI) from the cervix and abscess.12 Furthermore, Hoosen et al13 investigated the prevalence of STI pathogens including human immunodeficiency virus in women with Bartholin gland abscess. They collected aspirates from the abscess cavity and swab specimens from the vagina and endocervix before surgical drainage. In their study, antibodies to human immunodeficiency virus were detected in 30% of 30 patients. Recognized STI pathogens were detected in both aspirates and endocervical specimens: C trachomatis was detected in three aspirates and two endocervical specimens, whereas N gonorrhoeae was cultured in five aspirates and seven endocervical specimens. They recommended comprehensive treatment of STI including C trachomatis in women with Bartholin gland abscesses.13
According to the Israeli Ministry of Health data, the prevalence of N gonorrhoea and C trachomatis is lower than most industrialized countries.14 In our study there were no positive cultures for common STI pathogens. Our results correlate with those of others that have found STI pathogens to be negligible.6,8 However, special swabs for N gonorrhoea as well as polymerase chain reaction for N gonorrhoea and C trachomatis diagnosis were not used. Based on these results, it appears that STI workup and coverage in patients presenting with Bartholin gland abscess may not be routine and could be reserved for patients in whom STIs are suspected on clinical or epidemiologic grounds. This approach should be corroborated by studies in which appropriate specimens for STIs are being used.
The literature regarding Bartholin gland abscess during pregnancy is very scarce and is limited to case reports that mainly depict severe infective complications such as chorioamnionitis and sepsis or infection with unusual pathogens.15,16 In addition, risk for complicated infection can increase as a result of delayed diagnosis and there is some concern regarding the use of antibiotics. There is also a limitation in administering some antimicrobials during pregnancy. In our study, 5.5% were parturient while presenting with Bartholin gland abscess. Because the immune system is altered during normal pregnancy and pregnancy is considered an immune-modulated state, administration of antimicrobial therapy should be considered in that group.
Another important aspect of our study relates to the recurrence of Bartholin gland abscess. In our study, 37% of cases were recurrent Bartholin gland abscesses, which is in agreement with previous studies that have reported a recurrence rate of between 0% and 385%.17 We are not aware of any studies that investigated the location of a recurrent Bartholin gland abscess. We found that in the majority of the patients, recurrence occurred on the same side and the mean time for recurrence after the primary event was 32±50 months (median 12 months, range 0.5–240.5 months). The rate of recurrent cases (37%) is probably underestimated by a maximal follow-up period of 5 years for primary cases and therefore does not represent the true recurrence rate. In addition, we identified an association between infecting pathogen and recurrence. This information is of great value to both the patient and attending physicians.
Resistance to antimicrobials has spread globally over recent years and poses therapeutic challenges. Specifically, the emergence of extended-spectrum beta-lactamases, enzymes produced by Gram-negative enteric bacilli that inactivate a wide range of first-line antimicrobial agents, is of growing concern (including penicillins and first-, second- and third-generation cephalosporins). This is true especially in acute care settings.18 Extended-spectrum beta-lactamases have now spread in the community19 and reports of extended-spectrum beta-lactamases complicating gynecologic and perinatal infections begin to accumulate.20 Extended-spectrum beta-lactamases appear to be a newly emerging challenge in Bartholin gland abscesses and thus our findings have implications on the management of such patients, both in relation to the choice of broader-spectrum empirical antimicrobials as well as infection control measures to prevent the spread of resistance.
Our study offers several strengths; our data included a relatively large sample size that has a major effect on current published data regarding the diagnosis and management of Bartholin gland abscess given the limited existing literature. In addition, analysis of microbiological results was augmented by studying clinical parameters such as fever and leukocytosis. Finally, data in this study are based on physician-generated reports during the primary diagnosis and treatment of patients, which makes the potential for recall and selection bias less likely. A potential limitation of the study is the relatively high rate of negative cultures and the lack of appropriate testing for STIs. In our study, only 61.8% of cases had positive cultures and this may have resulted in differential misclassification. However, this culture positivity rate is in agreement with other published data. In a study by Bhide et al,1 33 of 45 cultured cases (73.3%) were positive. In a previous study by Bleker et al,12 less than half of the cases had positive cultures. Another limitation of the study is the use of swabs for microbial culture, which could have led to underestimation of anaerobic bacteria. These limitations should be addressed in future research.
In conclusion, Bartholin gland abscess is a relatively common gynecologic problem. High rates of positive cultures were found with the most common pathogen being E coli. Our microbiological findings and their clinical correlates demonstrated in this study are of major importance when performing a primary diagnosis and providing treatment to patients with Bartholin gland abscess. Empirical antimicrobial treatment during the primary diagnosis may be applicable for several patient subgroups and should be based on microbiological data. Based on our results, amoxicillin–clavulanate may be an appropriate empirical choice. Empirical regimens should be periodically reviewed as a result of the possible emergence of antimicrobial resistant strains such as those producing extended-spectrum beta-lactamases.
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© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.