OMPHALITIS

OMPHALITIS

 Def : Infection of the umbilicus and/or surrounding tissues.
Incidence : approximately 1 in 1,000 infants in developed countries where aseptic delivery and hygienic dry cord care are practiced.

The risk factors associated with the development of omphalitis include:

• prolonged rupture of membranes
• maternal infection
• nonsterile delivery practices
• home delivery
• umbilical catheterization
• low birth weight
• improper cord care or cultural practices of cord care (such as application of cow dung, charcoal dust, or products such as cooking oil and baby powder to the cord stump, and lotus births)
• delayed cord separation
• immunologic conditions such as defects in leukocyte adhesion, neutrophil or natural killer lymphocyte function, and interferon production.

Clinical features:
Mild discharge from the umbilical stump in the absence of inflammatory signs may be a normal occurrence, even when accompanied by some odor.

Unhealthy, discolored, and craggy-appearing umbilical stump; purulent drainage; periumbilical erythema; and induration.

Umbilical stump bleeding may occur with omphalitis because the infection delays thrombosis of the umbilical vessels.

Systemic signs, including lethargy, fever, irritability, temperature instability and poor feeding are suggestive of more severe infection or complication. The most common complication of omphalitis is sepsis.

Other complications include septic umbilical arteritis, portal vein thrombosis, liver abscess, peritonitis, intestinal gangrene, small bowel evisceration, necrotizing fasciitis, and death (Mortality rate is estimated between 7 and 15 percent)
 

Omphalitis is a polymicrobial infection. Historically, the predominant pathogens included Staphylococcus aureus, Streptococcus pyogenes, and Gram-negative bacteria such as Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. However, with the routine use of antistaphylococcal cord care regimens, Gram-negative infections of the umbilicus have increased . In addition, anaerobic bacteria such as Bacteroides fragilis, Clostridium perfringens, and Clostridium tetani can contribute to umbilical infections, especially in infants born to mothers with chorioamnionitis . In these infants, foul smelling umbilical drainage is a typical finding.

Management :
 Whenever possible, cultures of the discharge should be obtained prior to the start of antibiotic therapy. Blood and cerebrospinal fluid cultures should also be obtained in infants with systemic signs (eg, fever) as they are more likely to be septic or develop meningitis.
Antibiotic treatment of omphalitis is required and is directed against Gram-positive and Gram-negative organisms .

In the neonate, parenterally administered antistaphylococcal penicillin and aminoglycoside agents are administered to decrease the risk of significant complications, such as sepsis and necrotizing fasciitis.

 In communities with a high prevalence of methicillin-resistant S. aureus, vancomycin should be used in place of an antistaphylococcal penicillin.

Clindamycin or metronidazole also has been suggested in the treatment of infants with omphalitis for anaerobic coverage, especially those with foul smelling discharge or born to mothers with amnionitis.

We typically administer a 10-day course of intravenous antibiotics in neonatal patients, which can be modified dependent upon the patient's clinical response and whether complications develop.

Some clinicians treat infants with minimal symptoms with topical applications such as alcohol, bacitracin, or mupirocin. However, there is no evidence of efficacy of this practice or on the efficacy of the administration of oral antibiotics in these infants.

In older patients, similar antibiotic coverage can be administered orally, and is modified based on culture results and clinical improvement.

References:

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