Abscesses and Cellulitis
The infection is usually polymicrobial in nature, with both aerobic and anaerobic (Bacteroides species and other colonic and vaginal bacteria) flora. C. trachomatis and N. gonorrhoeae are encountered frequently.
The treatment of Bartholin's glands infections depends on the patient's symptoms. Asymptomatic women less than 40 years of age do not need treatment. Therapy for symptomatic cellulitis, with or without an abscess, consists of broad-spectrum antibiotics and warm sitz baths. In the case of isolated abscesses without evidence of cellulitis, antibiotics are not necessary (44). Spontaneous rupture and drainage of an abscess sometime occurs, but recurrence is likely. Definitive treatment involves surgical drainage with a Word catheter, marsupialization, or excision. The former two treatments are office-based procedures and can be performed using local anesthesia.
The treatment of choice for a symptomatic abscess is a Word catheter, which provides a convenient and highly successful method of creating a fistula from the duct of the gland to the vestibule. Most cases resolve after a few days of drainage and the catheter often falls out within a week. Ideally, the catheter should remain in place for four to six weeks, during which time an epithelial sinus will form. Sitz baths two to three times daily after the procedure may help with discomfort, keep the area clean, and hasten the healing process. Coitus may be resumed after catheter insertion.
If the abscess is too deep, Word catheter placement is impractical, and other options must be considered. Simple incision and drainage is an easy procedure but is discouraged because of the high risk of abscess recurrence, which has been reported as high as 13% (44). Also, incision and drainage may complicate later attempts at Word catheter placement or marsupialization. Nonetheless, if a Word catheter proves ineffective, incision and drainage is an acceptable option before proceeding to surgical excision. The incision for abscess drainage should be made on the mucosal, rather than the cutaneous surface. If the abscess recurs, more definitive therapy in the form of marsupiali-zation or complete excision of the gland may be required, but these procedures are not the initial treatment of choice.
Marsupialization is a more complex procedure, involving incision and drainage followed by suturing the walls of the cyst to the skin. As with Word catheters, postoperative sitz baths can be beneficial. The recurrence rate following marsupialization is approximately 5% to 15% (44). Complications include dyspareunia, hematoma, and infection. There is a report of sepsis after marsupia-lization of a Bartholin's gland abscess in a gravida (45) and pregnant women should be considered high risk and managed accordingly.
Excision of Bartholin's gland and duct is another option. Though some clinicians routinely suggest excisional surgery following the first infection, more commonly surgery is reserved for the patient with persistent infection or multiple abscess recurrences. Some experts advocate for excision and biopsy for gland enlargement in women more than 40 years of age in order to evaluate for possible Bartholin's gland adenocarcinoma (13). Excision should be performed only in the absence of active infection. This is not an office procedure, as regional block or general anesthesia is necessary. Associated complications include intraoperative hemorrhage, hematomas, scarring, and dyspareunia.
The presence of cellulitis, deteriorating vital signs, and a deep, spreading, painful erythema, especially in the postpartum or postoperative patient, should raise concern for necrotizing fasciitis. Necrotizing fasciitis is a rapidly progressive infection commonly caused by mixed aerobic-anaerobic bacteria. Unfortunately, antibiotic treatment usually proves ineffective. Necrotizing fasciitis is a surgical emergency requiring immediate and extensive surgical debridement of the necrotic fascia to prevent septic shock and fatal complications. Patients may require several debridements and skin grafts are often needed to repair large defects. Due to the emergent nature of this condition, women presenting with vulvar cellulitis, with risk factors for necrotizing fasciitis (obesity, diabetes mellitus, corticosteroid use, or immunosuppressed states) should be hospitalized for treatment with intravenous broad-spectrum antibiotics, including a penicillin and surgical treatment (46).
Treponema pallidum (Syphilis)
For over 50 years, administration of penicillin G to patients with syphilis has resulted in resolution of lesions and decreased transmission rates, and has prevented sequelae of the disease effectively. On the basis of the clinical results, penicillin is accepted as the treatment of choice for syphilis. No comparative trials have been conducted to determine the optimal dose, preparation, or length of therapy. The efficacy of most treatment recommendations is based on experience with the disease supported by case studies, clinical trials, and clinical experience. Data are not reinforced by results from RCTs, but at this time, conducting such a trial would most likely be of little additional benefit.
Parenteral penicillin G is the preferred drug for the treatment of all stages of syphilis (47) (treatment for tertiary syphilis will not be discussed further). For primary and secondary syphilis, the recommended treatment regimen is a single dose of benzathine penicillin G, 2.4 million U intramuscularly. If within six months of treatment, nontreponemal titers do not decrease four-fold, the patient should be retreated with benzathine penicillin G, 2.4 million U intramuscularly weekly for three weeks.
Treatment alternatives for penicillin-allergic patients include doxycycline (100 mg twice daily for 14 days), tetracycline (500 mg 4 times daily for 14 days), erythromycin (30-40 g given in divided doses over a period of 10 -15 days), or penicillin desensitization. Tetracycline can cause gastrointestinal side effects; the other agents may increase the patient's compliance.
Some data demonstrate the efficacy of ceftriaxone for the treatment of early syphilis. However, the optimal dose and duration of therapy have not been defined clearly. The current recommendation is 1 g daily either intramuscularly or intravenously for 8 to 10 days.
Small studies, including one randomized comparative pilot study, indicate that azithromycin, as a single oral dose of 2 g or two doses one week apart, may be effective in treating early primary syphilis (48). This treatment is an attractive future alternative because it is administered orally. Recent reports have documented strains of T. pallidum with functional resistance to azithromycin (49).
Because they currently lack recommendation by the Center for Disease Control (CDC), and their efficacy are supported by limited data, clinicians must follow patients receiving ceftriazone and azithromycin closely.
Regardless of the drug used for treatment, patients treated for syphilis may develop the Jarisch-Herxheimer reaction, an acute febrile reaction starting within 24 hours of treatment initiation. This condition is characterized by fever, headache, and myalgias. Patients should be informed about this possible adverse reaction.
Parenteral penicillin G is the only documented efficacious treatment for syphilis during pregnancy. Thus, penicillin-allergic pregnant women with syphilis in any stage should be desensitized and treated with penicillin. Tetra-cycline and doxycycline should not be used during pregnancy. Erythromycin should not be used because it does not cure the infected fetus reliably. The Jarisch-Herxheimer reaction may induce early labor or cause fetal distress; however, this concern should not delay or prevent therapy.
Haemophilus ducreyi (Chancroid)
Successful treatment for chancroid cures the infection, resolves the clinical symptoms, and prevents transmission to others. Recently, H. ducreyi has shown resistance to many pharmacologic agents, such as trimethoprim-sulfametrole, penicillin, and tetracycline, some of which have been used traditionally for its treatment. Worldwide, there have been reports of isolates with intermediate resistance to ciprofloxacin, ceftriaxone, and erythromycin. Current regimens accepted by the World Health Organization (WHO) and CDC are as follows: oral erythromycin (500 mg three or four times a day for seven days), oral azithromycin (1 g single dose), intramuscular ceftriaxone (250 mg single dose), oral ciprofloxacin (500 mg twice a day for three days), oral ciprofloxacin (500 mg single dose), and spectinomycin (2 g single dose, intramuscularly) (47,50).
Intramuscular azithromycin and ceftriaxone allow for one-dose therapy. For ciprofloxacin, there is some debate concerning the duration of therapy; the WHO recommends a single 500 mg oral dose and the CDC recommends 500 mg daily for three days. A recent double-blind, RCT showed comparable cure rates (51). The WHO and CDC also differ in their recommendations of the frequency of dosing of erythromycin. The WHO recommends 500 mg treatment four times per day, whereas the CDC recommends the same dose three times per day. Both regimens appear effective.
With treatment, buboes smaller than 5 cm typically resolve in one to two weeks. Larger buboes, as well as fluctuant buboes, should be aspirated or incised, and drained for symptomatic relief and to avoid spontaneous rupture, chronic ulceration, and tissue loss. Partners should be examined and treated and sexual contact should be avoided until treatment is complete and lesions have resolved. Pregnant women should be treated with either erythromycin or ceftriaxone regimens.
Patients with HIV infection have reduced healing and persistent infection and, therefore, should have careful follow-up.
Donovanosis (Granouloma inguinale, Calymmatobacterium granulomatis)
Few trials report appropriate antibiotic choice or duration of therapy for treatment of Donovanosis. However, current CDC recommendations are as follows (47): oral trimethoprim-sulfamethoxazole 800 mg/160 mg twice daily or oral doxycy-cline 100 mg twice daily. Alternatives include ciprofloxacin 750 mg twice daily, erythromycin base 500 mg four times a day, and azithromycin 1 g once per week. Regardless of antibiotic choice, treatment should be continued for at least three weeks or until the lesions have healed. Larger lesions may require longer periods of treatment. Some clinicians recommend adding an aminoglycoside, such as gentamicin 1 mg/kg intravenously every eight hours, if improvement is not apparent within the first few days of therapy.
Patients should be seen regularly until symptoms resolve. Follow-up is essential, as patients may relapse 6 to 18 months after seemingly effective treatment.
Pregnant and lactating women should be treated with erythromycin, with consideration given to the addition of gentamicin. Azithromycin may prove efficacious in this population, but there currently are no published data.
Lymphogranuloma venereum (Chlamydia trachomatis strain)
Oral doxycycline (100 mg, twice a day for three weeks) is the drug of choice for this genital infection. Oral erythromycin (500 mg four times a day for 21 days) is an appropriate alternative (47). Azithromycin (1 g once weekly for three weeks) appears effective, although there are no supporting clinical data. Successful treatment provides symptomatic relief, cures the infection, and prevents continued tissue damage. Scarring, which results from tissue reaction, is unaffected by antibiotic treatment. Buboes can persist, as they are not affected by antibiotic therapy. Persistent buboes may require aspiration or incision and drainage.
Patients should be followed clinically until signs and symptoms have resolved. Pregnant and lactating women should be treated with erythromycin.
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