eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Omphalitis: Treatment & Medication

Author: Patrick G Gallagher, MD, Assistant Fellowship Program Director, Associate Professor, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Yale University and Yale-New Haven Children's Hospital
Coauthor(s): Samir S Shah, MD, Staff Physician, Departments of Pediatrics and Immunologic and Infectious Diseases, The Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Jan 16, 2009

Treatment

Medical Care

Treatment of omphalitis (periumbilical edema, erythema, and tenderness) in the newborn includes antimicrobial therapy and supportive care.

  • Antimicrobial therapy
    • Include parenteral antimicrobial coverage for gram-positive and gram-negative organisms. A combination of an antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended.
    • Some believe that anaerobic coverage is important in all patients. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, with antimicrobial therapy directed at anaerobic organisms as well as gram-positive and gram-negative organisms. Metronidazole or clindamycin may provide anaerobic coverage.
    • Pseudomonas species have been implicated in particularly rapid or invasive disease.
    • As with antimicrobial therapy for other infections, consider local antibiotic susceptibility patterns, particularly patterns of S aureus and enterococcal susceptibility.
    • Additional topical therapy with triple dye, bacitracin, and other antimicrobials has been suggested in addition to parenteral antibiotic therapy, but such treatment is unproven.
  • Supportive care: In addition to antimicrobial therapy, supportive care is essential to survival. These measures include the following:
    • Provide ventilatory assistance and supplementary oxygen for hypoxemia or apnea unresponsive to stimulation.
    • Administer fluid, vasoactive agents, or both (as indicated) for hypotension.
    • Administration of platelets, fresh frozen plasma, or cryoprecipitate for disseminated intravascular coagulation (DIC) and clinical bleeding is suggested.
    • Treat infants at centers capable of supporting cardiopulmonary function.
  • Other treatment considerations
    • Monitor patients for progression of disease. Early surgical intervention may be lifesaving.
    • In uncomplicated cases, expect erythema of the umbilical stump to improve within 12-24 hours after the initiation of antimicrobial therapy. Failure to respond may suggest disease progression, presence of an anatomic defect, or an immunodeficiency state.
    • The role of hyperbaric oxygen in treatment of patients with anaerobic necrotizing fasciitis and myonecrosis is controversial because no prospective controlled data are available and pediatric data are scarce. In the treatment chambers, tissue levels of oxygen are maximized when the patient breathes 100% oxygen at 2-3 atm. The delivery of high concentrations of oxygen to marginally perfused tissues may have a detrimental effect on the growth of anaerobic organisms and improve phagocyte function. However, surgical therapy has the highest priority, and initiation of hyperbaric oxygen therapy should not delay transport to a facility with staff capable of performing surgical debridement.

Surgical Care

Management of necrotizing fasciitis and myonecrosis involves early and complete surgical debridement of the affected tissue and muscle.25,26

  • Although the extent of debridement depends on the viability of tissue and muscle, which is determined at the time of surgery, excision of preperitoneal tissue (including the umbilicus, umbilical vessels, and urachal remnant) is critically important in the eradication of the infection.
  • These tissues can harbor invasive bacteria and provide a route for progressive spread of infection after less extensive debridement.
  • Delay in diagnosis or surgery allows progression and spread of necrosis, leading to extensive tissue loss and worsening systemic toxicity.
  • Several surgical procedures may be required before all nonviable tissue is removed.

Consultations

  • Infectious disease specialist - For appropriate antimicrobial selection, particularly if necrotizing fasciitis or myonecrosis occurs
  • Surgeon - If necrotizing fasciitis or myonecrosis is suspected (consult early in the disease course)

Diet

  • Once omphalitis is suspected, do not feed the infant enterally. Enteral feedings may be resumed once the acute infection resolves.
  • Parenteral nutrition is required in infants with omphalitis.

Medication

A combination of parenterally administered antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended for uncomplicated omphalitis. Some believe that anaerobic coverage also should be considered in all infants with omphalitis. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, and antimicrobial therapy directed at anaerobic organisms, as well as gram-positive and gram-negative organisms, is suggested. Metronidazole may be added to the combination of antistaphylococcal penicillin and aminoglycoside to provide anaerobic coverage, or clindamycin may be substituted for antistaphylococcal penicillin. As with antimicrobial therapy for other infections, consider local antibiotic susceptibility patterns and results of blood and biopsy specimen culturing.

Blood products (eg, packed RBCs, platelets, fresh frozen plasma) and other medications (eg, inotropic agents, sodium bicarbonate) may be required for supportive care.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.27


Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination both with an agent against gram-positive organisms and with an agent that covers anaerobes.

Adult

Pediatric

Neonatal dosage dependent on PMA and postnatal age
PMA <29 weeks and postnatal age 0-7 days: 5 mg/kg/dose IV q48h
PMA <29 weeks and postnatal age 8-28 days: 4 mg/kg/dose IV q36h
PMA <29 weeks and postnatal age >29 days: 4 mg/kg/dose IV q24h
PMA 30-34 weeks and postnatal age 0-7 days: 4.5 mg/kg/dose IV q36h
PMA 30-34 weeks and postnatal age >8 days: 4 mg/kg/dose IV q24h
PMA >35 weeks (any postnatal age): 4 mg/kg/dose IV q24h

Amphotericin B, cyclosporine, cephalosporins, or furosemide may increase the risk of renal toxicity; coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Nephrotoxicity and ototoxicity may be associated with prolonged elevated trough concentrations; monitor levels to minimize risk of toxicity and to optimize therapy (ie, peak 6-10 mg/L, trough <2 mg/L); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Oxacillin (Bactocill)

Antistaphylococcal penicillin. Bactericidal antibiotic that inhibits cell wall synthesis. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when staphylococcal infection is suspected.

Adult

Pediatric

Neonatal dosing adjusted by PMA and postnatal age
PMA <29 weeks and postnatal age 0-28 days: 25 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 25 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 25 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 25 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 25 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 25 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 25 mg/kg/dose IV/PO q6h

Probenecid decreases elimination

Documented hypersensitivity; patients with combined renal and hepatic impairment

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause rash and bone marrow suppression; caution in renal insufficiency (decrease dose)


Clindamycin (Cleocin)

Used to treat infections caused by anaerobic bacteria. Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Adult

Pediatric

Neonatal dosage dependent on PMA and postnatal age
PMA <29 weeks and postnatal age 0-28 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 5-7.5 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 5-7.5 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 5-7.5 mg/kg/dose IV/PO q6h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; meningitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May cause diarrhea, rash, granulocytopenia, thrombocytopenia, and Stevens-Johnson syndrome; adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Metronidazole IV (Flagyl)

Anaerobic antibiotic that also has amebicide and antiprotozoal actions.

Adult

Pediatric

Neonatal dosing adjusted by PMA and postnatal age
Loading dose: 15 mg/kg IV/PO
Maintenance doses: 7.5
PMA <29 weeks and postnatal age 0-28 days: 7.5 mg/kg/dose IV/PO q48h
PMA <29 weeks and postnatal age >28 days: 7.5 mg/kg/dose IV/PO q24h
PMA 30-36 weeks and postnatal age 0-14 days: 7.5 mg/kg/dose IV/PO q24h
PMA 30-36 weeks and postnatal age >14 days: 7.5 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age 0-7 days: 7.5 mg/kg/dose IV/PO q24h
PMA 37-44 weeks and postnatal age >7 days: 7.5 mg/kg/dose IV/PO q12h
PMA >45 weeks (any postnatal age): 7.5 mg/kg/dose IV/PO q8h

May increase levels or toxicity of phenytoin, lithium, and warfarin; phenobarbital and rifampin may increase metronidazole metabolism; disulfiram reaction may occur with PO ingested ethanol (caution with elixir preparations)

Documented hypersensitivity; liver disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Requires dose adjustment in patients with renal and liver disease; may cause CNS toxicity (eg, seizures, neuropathy, headache, vomiting)


Ampicillin

Broad-spectrum penicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Bactericidal for organisms, such as GBS, Listeria, non–penicillinase-producing staphylococci, some strains of Haemophilus influenzae, and meningococci.

Adult

Pediatric

Neonatal dosing adjusted by PMA and postnatal age
PMA <29 weeks and postnatal age 0-28 days: 25-50 mg/kg/dose IV/PO q12h
PMA <29 weeks and postnatal age >28 days: 25-50 mg/kg/dose IV/PO q8h
PMA 30-36 weeks and postnatal age 0-14 days: 25-50 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 25-50 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 25-50 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 25-50 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 25-50 mg/kg/dose IV/PO q6h
Note: 100 mg/kg/dose may be considered for meningitis or group B streptococcal sepsis

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of PO contraceptives

Pregnancy
Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction


Vancomycin (Vancocin, Vancoled)

Bacteriocidal agent against most aerobic and anaerobic gram-positive cocci and bacilli. Especially important in the treatment of MRSA. Recommended therapy when coagulase-negative staphylococcal sepsis is suspected.

Adult

Pediatric

Neonatal dosing adjusted by PMA and postnatal age
PMA <29 weeks and postnatal age 0-28 days: 10 mg/kg/dose IV/PO q18h
PMA <29 weeks and postnatal age >28 days: 10 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age 0-14 days: 10 mg/kg/dose IV/PO q12h
PMA 30-36 weeks and postnatal age >14 days: 10 mg/kg/dose IV/PO q8h
PMA 37-44 weeks and postnatal age 0-7 days: 10 mg/kg/dose IV/PO q12h
PMA 37-44 weeks and postnatal age >7 days: 10 mg/kg/dose IV/PO q8h
PMA >45 weeks (any postnatal age): 10 mg/kg/dose IV/PO q6h
Note: 15 mg/kg/dose may be considered for meningitis

Erythema, histamine-like flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy
Precautions

Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction

More on Omphalitis

Overview: Omphalitis
Differential Diagnoses & Workup: Omphalitis
Treatment & Medication: Omphalitis
Follow-up: Omphalitis
References
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Further Reading

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Keywords

omphalitis, umbilicus, umbilical cord, umbilical stump, umbilicus infection, umbilical infection, umbilical stump infection, necrotizing fasciitis, myonecrosis, Staphylococcus aureus, group A Streptococcus, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, fragilis, Peptostreptococcus species, Clostridium perfringens, tetanus, sepsis, septic embolization, jaundice, cellulitis, petechiae, crepitus, bullae, leukocyte adhesion deficiency, LAD, patent urachus, patent omphalomesenteric duct, urachal cyst, disseminated intravascular coagulation, DIC, hypoglycemia, hypocalcemia, metabolic acidosis

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Contributor Information and Disclosures

Author

Patrick G Gallagher, MD, Assistant Fellowship Program Director, Associate Professor, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Yale University and Yale-New Haven Children's Hospital
Patrick G Gallagher, MD is a member of the following medical societies: American Society of Hematology and American Society of Human Genetics
Disclosure: Nothing to disclose.

Coauthor(s)

Samir S Shah, MD, Staff Physician, Departments of Pediatrics and Immunologic and Infectious Diseases, The Children's Hospital of Philadelphia
Samir S Shah, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Shelley C Springer, MD, MBA, MSc, FAAP, JD LS-3, Clinical Instructor, Department of Pediatrics, University of Wisconsin; Neonatologist, Pediatrix Medical Group; Assistant Clinical Professor, Department of Pediatrics, University of North Texas Science Center; Assistant Clinical Professor, Department of Pediatrics, Texas A & M University
Shelley C Springer, MD, MBA, MSc, FAAP, JD LS-3 is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, National Hospice and Palliative Care Organization, and National Perinatal Association
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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