Background
Bartholin glands are mucus-secreting glands on bilateral lower portions of the vaginal introitus at 4 and 8 o’clock [1]. While they are not normally palpable, cysts and abscesses are a common due to obstruction. 2% of gynecologic visits a year are due to symptomatic Bartholin cysts or abscesses [1]. Increasing pain, edema, fluctuance, induration, or purulent drainage are all indications of an abscess and require management with incision and drainage, wood catheter placement, and potential antibiotics [1]. Bartholin abscesses greater than 2 cm do not normally resolve on their own and require drainage to prevent reoccurrence [2]. Bartholin abscesses have frequent rates of reoccurrence (38%) and therefore adequate preliminary treatment is crucial [3].
Case Presentation
21 y/o female G0 with no past medical history presented to the emergency department with enlarging Bartholin cyst for the past 3 months. 3 months prior, she had an STD exposure and dysuria and was empirically treated with ceftriaxone and azithromycin, with subsequent positive nucleic amplification assay for both gonorrhea and chlamydia. She also had a Bartholin cyst which providers recommended a trial of warm compresses and sitz baths. However, for the past 2-3 days, the cyst had been enlarging with increasing tenderness (especially with walking/sitting), subjective fevers and chills.
On admission, patient presented with a BP 118/67, pulse 112, and temperature 37.9 °C (100.3 °F). On her exam, her left labium was edematous and tender with small mobile fluctuant area that was very tender. In the ED, an Incision & Drainage (I&D) and Word catheter placement was attempted and unsuccessful with no external drainage.
On labs, she had a significant leukocytosis with a left shift (WBC 23.2 [ref: 4.8 - 10.8] 10E3/uL, 84.2% [ref: 37.0 - 75.0 %] neutrophils), blood urea nitrogen (BUN) 14 [ref: 7 - 25] mg/dL, and creatinine (Cr) 0.54 [ref: 0.60 - 1.30] mg/dL. On CT pelvis without contrast, a 6.8 x 4.5 x 4.9 cm cystic mass in left labium was noted.
Gynecology admitted patient for IV antibiotics (Vancomycin and piperacillin-tazobactam), Tylenol/ibuprofen for antipyretic and pain management, and kept patient NPO for potential examination under anesthesia if no improvement. However, within a few hours she was persistently febrile, tachycardic, and the abscess site was increasing in size to about a 10 x 5 cm. She was taken to the OR where hematoma was detected and evacuated from the previous I&D site and drained a moderate amount of purulent fluid from the left labia majora, sent for culture. Postoperatively, she was started on PO Bactrim every 12 hours for 7 days.
Her repeat CBC after 24 hours showed an elevated Cr 2.24 [ref: 0.60 - 1.30] mg/dL and normal BUN 14 [ref: 7 - 25] mg/dL with an elevated vancomycin of 53 mcg/mL. She was given a 500 cc lactated ringers bolus, then D5W 0.45% NaCl IV fluids were up titrated from 50 mL/hr to 150 mL/hr, and pharmacy adjusted her vancomycin. Overall, patient was well-appearing with some mild nausea and vomiting, 24 hours afebrile. Her WBC count down trending to 18.4 [ref: 4.8 - 10.8] 10E3/uL.
On day 3, her acute kidney injury continued to worsen with AM Cr 4.57 [ref: 0.60 - 1.30] mg/dL. At this time, all nephrotoxic drugs were discontinued (Motrin, Vancomycin, piperacillin-tazobactam, and Bactrim). IV fluids were continued and supportive care, with monitoring daily weights and urine outputs. Blood cultures, urine cultures, and vulvar cultures remained negative. MRSA nares negative. Renal ultrasound was negative. HIV was negative.
The next few days (day 4 to 7), Cr continued to trend upwards 6.32 mg/dL, 7.55 mg/dL, 8.30 mg/dL, 8.55 mg/dL as the vancomycin level slowly trended downwards from 39.1 mcg/mL to 30.4 mcg/mL. Cr began to plateau around 8.3 mg/dL by day 9 and was discharged with weekly BMPs and outpatient follow-up with Nephrology. She was given one 1L normal saline bolus prior to discharge.
Discussion
Empiric antibiotic therapy in Bartholin abscesses are indicated in the setting of signs of systemic infection such as fever, tachycardia, and increasing erythema, tenderness, or fluctuance. Empiric antibiotics should cover anaerobes and gram negative due to native vaginal flora as well as gram positives such as Staph and specifically MRSA [1]. Recently studies have shown E.coli commonly implicated in Bartholin gland abscesses, making amoxicillin-clavulanate an appropriate empiric outpatient choice [4]. Inpatient admission is recommended in patients with worsening infection, temperature greater than 38°C, tachypnea, tachycardia (greater than 90 bpm), or worsening white blood cell count (> 12,000) [2]. These patients should be monitored more closely with IV antibiotic coverage. Sexually transmitted infections are also commonly implicated with studies to show a role in causing Bartholin cyst abscesses and STD testing can be considered in these settings [5].
While antibiotic choice is up to clinical judgement, it is recommended to cover for MRSA in the setting inpatient infection, typically with the use of vancomycin [1]. For broad empiric coverage, vancomycin is commonly combined with cefepime, carbapenems, or piperacillin-tazobactam. Nephrotoxicity is a well-established side effect of vancomycin, anti-inflammatory drugs, and other systemic antibiotics [6]. Vancomycin-induced acute kidney injury is estimated from 1.0 to 42%, with increased risk in patients on other nephrotoxic drugs, prolonged treatment, and high daily dosing [7-10]. Therefore, it is important to monitor the serum levels, volume status, and creatinine of patients and to be wary of nephrotoxic drug combinations [6]. Systemic reviews are increasingly commenting on the increased incidence of acute kidney injury due to the combination of vancomycin and piperacillin-tazobactam as opposed to other drug combination therapies (cefepime or meropenem) [11]. A metanalysis of 47 cohort studies with 59, 984 patients showed higher nephrotoxicity rates of vancomycin and piperacillin-tazobactam combination therapy than monotherapy or combination with meropenem/cefepime [12]. This drug combination is commonly implicated in the incidence of AKI during empiric antibiotic therapy and caution should be used in checking for further NSAID pain control that would further reduce GFR. Additional caution should be taken in patents who recently received IV contrast for imaging studies. It is important to de-escalate therapy as soon as possible, however cultures do not always yield a proper organism or sensitivity, such as this case.
Conclusion
When antibiotics are indicated in the treatment of Bartholin abscesses, it is important to remain cautious of side effects of combination empiric treatment. Nephrotoxicity is a common side effect of several antibiotics and it is important to find a low-risk drug combination when covering for MRSA as well as gram negative/anaerobes. Vancomycin and piperacillin-tazobactam are a common empiric drug therapy but is increasingly implicated for causing nephrotoxicity in healthy populations. When using vancomycin, it is important to maintain euvolemic volume status in patients as well as diligently follow basic metabolic panels and serum trough levels. Similarly, avoid the use of NSAIDs for pain control and IV contrast dye in these patients. Cultures may not always yield a proper organism to de-escalate therapy but amoxicillin-clavulanate is an appropriate choice for coverage when switching to oral therapy in the setting of Bartholin abscesses. STI’s are also potential cause of infection of Bartholin glands and should be evaluated in populations at risk.
Conflict of interest: None
Financial disclosure: None
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