Basics
Description
Omphalitis, an infection of the umbilical stump, begins in the neonatal period as a superficial cellulitis but may progress to necrotizing fasciitis, myonecrosis, or systemic disease.
Epidemiology
- Episodes of omphalitis are usually sporadic, but rare epidemics occur.
- Mean age of onset is 5 " 9 days in term infants and 3 " 5 days in preterm infants.
- Incidence varies from 0.2 to 0.7% of live births in developed countries and up to 21% of live births in developing countries.
Risk Factors
- Low birth weight
- Prior umbilical catheterization
- Septic delivery
- Male sex
General Prevention
- There are multiple methods used for umbilical cord care, many of which are acceptable.
- Antimicrobial agents applied to the umbilicus may decrease bacterial colonization and prevent omphalitis, particularly in developing countries.
- Effective methods of umbilical cord care:
- Clean, dry cord care (AAP/WHO recommended)
- Triple dye
- Topical 4% chlorhexidine
- 70% alcohol solution
- There is significant evidence to support the use of topical 4% chlorhexidine to prevent omphalitis in developing countries, although it does delay time to cord separation.
- There is no evidence that application of an antiseptic to the umbilical cord is better than clean, dry cord care in a hospital setting.
Pathophysiology
- Potential bacterial pathogens normally colonize the umbilical stump after birth.
- These bacteria invade the umbilical stump, leading to omphalitis.
- Established aerobic bacterial infection, necrotic tissue, and poor blood supply facilitate the growth of anaerobic organisms.
- Infection may also extend beyond the subcutaneous tissues to involve fascial planes (fasciitis), abdominal wall musculature (myonecrosis), and umbilical and portal veins (phlebitis).
Etiology
- Most cases of omphalitis are polymicrobial.
- The most common organisms include gram-positive cocci (Staphylococcus aureus, group A streptococci) and gram-negative enteric bacilli (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis).
- Gram-positive organisms predominate; however, antistaphylococcal cord care has led to an increase in colonization and infection with gram-negative organisms.
- Anaerobic bacteria, including Bacteroides fragilis and Clostridium perfringens, are most likely in cases complicated by necrotizing fasciitis or myonecrosis.
- Clostridium tetani and Clostridium sordellii are seen primarily in developing countries when cow dung is used in cord care.
Commonly Associated Conditions
- Leukocyte adhesion deficiency
- Omphalitis may be the initial manifestation of one of the leukocyte adhesion deficiencies (LADs).
- LADs are rare, autosomal recessive immunologic disorders affecting leukocyte adhesion to blood vessel walls.
- Cord separation requires the influx of leukocytes; therefore, this deficiency causes delayed separation and can cause concomitant omphalitis.
- Infants also may present with leukocytosis, absence of pus formation, impaired wound healing, and recurrent infections localized to the skin and mucosal surfaces.
- Treatment involves prompt recognition of infection and use of appropriate antibiotics. Severe cases may need hematopoietic stem cell transplantation.
- Neutropenia
- Omphalitis complicated by sepsis can be associated with neutropenia.
- Other syndromes of neonatal neutropenia may present initially with omphalitis.
- Neonatal alloimmune neutropenia: Maternal IgG antibodies cross the placenta and cause immune-mediated destruction of fetal neutrophils bearing antigens differing from mother 's.
- Other causes of neutropenia: autoimmune neutropenias, X-linked agammaglobulinemia, hyper-IgM immunodeficiency syndromes, HIV, glycogen storage disease type IB, or disorders of amino acid metabolism
- Anatomic abnormalities
- Patent urachus: The urachus, a tubular structure connecting the bladder to the umbilicus, should obliterate by the 5th gestational month. If it remains patent, a continuous, significant amount of urine can drain from the umbilicus.
- Persistent omphalomesenteric duct: congenital malformation where a communication exists between the umbilicus and the gut. Drainage consists of intestinal secretions.
- Excessive granulation tissue: results from delayed healing of cord stump. Drainage is serosanguinous and pink.
- Considerations in preterm infants:
- Preterm infants are more susceptible secondary to immature immune defenses (including the skin) and possible umbilical catheterization.
- These infants are more likely to present with omphalitis at an earlier age and with low neutrophil counts.
Diagnosis
History
- Identify risk factors such as prolonged membrane rupture and septic delivery.
- Symptoms such as fever, irritability, lethargy, respiratory distress, or feeding intolerance may indicate systemic dissemination of the infection.
- A history of urine or stool discharge from the umbilicus suggests an underlying anatomic abnormality.
- Family history may reveal individuals with metabolic disorders or recurrent infections.
Physical Exam
- Varies with the extent of disease
- Localized infection
- Abdominal tenderness
- Periumbilical edema and erythema
- Purulent or malodorous discharge from the umbilical stump
- Indications of more extensive local disease, such as necrotizing fasciitis or myonecrosis:
- Periumbilical ecchymoses or gangrene
- Abdominal wall crepitus
- Progression of cellulitis despite antimicrobial therapy
- Signs of systemic disease are nonspecific and include thermodysregulation and evidence of multiorgan dysfunction:
- Fever or temperature instability
- Tachycardia, hypotension, poor perfusion
- Respiratory distress
- Abdominal distention, diminished bowel sounds
- Cyanosis, petechiae, jaundice
- Lethargy, hypotonia
Diagnostic Tests & Interpretation
Lab
- Umbilical stump Gram stain and culture for aerobic and anaerobic organisms
- Identify potential organisms and antimicrobial susceptibility patterns. Cultures of umbilical discharge may reflect only colonization of the stump and are not proof of an etiologic role in the underlying process. If myonecrosis is suspected, muscle specimens should be cultured.
- Blood culture
- Identify systemic dissemination of infection
- CBC with differential
- Identify neutropenia or leukocytosis
- An immature-to-total neutrophil ratio >0.2 is suggestive of systemic infection.
- Thrombocytopenia may be present.
- D-dimers, prothrombin time, partial thromboplastin time, and fibrinogen
- Indicated for sepsis or disseminated intravascular coagulation
Imaging
Radiographs (case dependent)
- Abdominal radiographs
- Intestinal ileus may indicate systemic spread of infection; portal venous or intramural air requires immediate surgical consultation.
- Abdominal CT
- Confirms involvement of fascia and muscle and delineates the extent of infection
- May identify anatomic abnormalities
- Voiding cystourethrogram
Diagnostic Procedures/Other
Lumbar puncture: for any neonate with signs of focal/systemic illness or a positive blood culture
Differential Diagnosis
- The characteristic clinical picture of omphalitis allows diagnosis on clinical grounds.
- Determine the presence of associated complications, such as necrotizing fasciitis, myonecrosis, or systemic infection.
- Consider an underlying immunologic or metabolic disorder.
Treatment
Medication
Empiric coverage
- Antistaphylococcal agent (oxacillin, vancomycin) plus an aminoglycoside (e.g., gentamicin) or cefepime
- Consider local antibiotic susceptibility patterns when choosing antibiotics, paying particular attention to hospital and community incidence of methicillin-resistant S. aureus.
- Add anaerobic coverage (e.g., metronidazole or clindamycin) with necrotizing fasciitis or myonecrosis.
- Duration of therapy is typically 7 " 14 days.
Additional Treatment
General Measures
Antibiotics and supportive care
Issues for Referral
If systemic illness is present, infants may need referral to a tertiary care center and consultation by a pediatric infectious disease specialist or pediatric surgeon.
Surgery/Other Procedures
- Early and complete surgical debridement of affected tissue and muscle is important.
- Delay in diagnosis or surgical intervention allows local progression of infection and worsening systemic toxicity.
Inpatient Considerations
Initial Stabilization
Emergency care: Immediate evaluation, intravenous antimicrobial therapy, and supportive care are essential to survival.
Ongoing Care
Follow-up Recommendations
- Infants developing associated portal venous thrombosis require follow-up for complications owing to portal hypertension.
Prognosis
- The outcome of infants with uncomplicated omphalitis is generally good.
- The mortality rate among all infants with omphalitis, including those who develop complications, is 7 " 15%.
- The mortality rate is significantly higher (38 " 87%) with necrotizing fasciitis or myonecrosis.
Complications
- Systemic sepsis (up to 13% of cases)
- Evidenced by temperature instability, abdominal distension, respiratory distress, and/or hypotension
- Abscess
- Retroperitoneal, pelvic, cutaneous, hepatic
- Peritoneal complications
- Peritonitis can occur if the umbilical vein is involved in infection and is evidenced by poor feeding, bilious vomiting, and signs of systemic illness.
- Portal vein thrombosis or hepatic abscess can occur with transmission via the umbilical vein.
- Adhesive small bowel obstruction may be seen as a late complication.
- Myonecrosis
- Infectious involvement of the muscle
- Requires surgical treatment with resection
- Necrotizing fasciitis (8 " 16% of cases)
- Bacterial infection of the subcutaneous fat and superficial and deep fascia
- Characterized by rapidly spreading infection and systemic toxicity
Additional Reading
- Anderson J, Philip A. Management of the umbilical cord: care regimens, colonization, infection, and separation. Neoreviews. 2004;5:155 " 163.
- Evens K, George J, Angst D, et al. Does umbilical cord care in preterm infants influence bacterial colonization or detachment? J Perinatol. 2004;24(2):100 " 104. [View Abstract]
- Fraser N, Davies BW, Cusack J. Neonatal omphalitis: a review of its serious complications. Acta Paediatr. 2006;95(5):519 " 522. [View Abstract]
- Guvenc H, Aygun D, Yasar F, et al. Omphalitis in term and preterm appropriate for gestational age and small for gestational age infants. J Trop Pediatr. 1997;43(6):368 " 372. [View Abstract]
- Imdad A, Bautista R, Senen K, et al. Umbilical cord antiseptics for preventing sepsis and death among newborns. Cochrane Database Syst Rev. 2013;5:CD008635. [View Abstract]
- van de Vijver E, van den Berg TK, Kuijpers TW. Leukocyte adhesion deficiencies. Hematol Oncol Clin North Am. 2013;27(1):101 " 116. [View Abstract]
Codes
ICD09
- 771.4 Omphalitis of the newborn
- 041.00 Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified
- 041.10 Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified
ICD10
- P38.9 Omphalitis without hemorrhage
- B95.0 Streptococcus, group A, causing diseases classd elswhr
- B95.8 Unsp staphylococcus as the cause of diseases classd elswhr
- P38.1 Omphalitis with mild hemorrhage
SNOMED
- 42052009 Omphalitis of the newborn (disorder)
- 403843007 Streptococcal omphalitis of newborn (disorder)
- 403841009 Staphylococcal omphalitis of newborn (disorder)
FAQ
- Q: Do all preterm infants require antiseptic treatment of the umbilical cord?
- A: No. Although preterm infants are at higher risk for omphalitis, there is no evidence to support antimicrobial treatment of the umbilical cord over clean, dry cord care in a hospital setting. If born in a developing country or out of asepsis, antimicrobial cord care is recommended.
- Q: Is omphalitis always restricted to the umbilical stump?
- A: No. Omphalitis can invade the periumbilical skin, the abdominal wall, and the peritoneum. Prompt treatment is necessary to prevent systemic spread of infection.