Omphalitis Treatment & Management

Updated: May 20, 2019
  • Author: Patrick G Gallagher, MD; Chief Editor: Santina A Zanelli, MD  more...
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Treatment

Approach Considerations

Transfer

Critically ill infants, including those who may require surgical intervention, may require transfer to an intensive care unit equipped to treat infants. Transport the patient with advanced life support technology in place and qualified personnel in attendance. Options for further treatment or intervention must be immediately available. (See Transport of the Critically Ill Newborn.)

Consultations

The following consultations may be indicated:

  • 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)

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Medical Care

Treatment of omphalitis (periumbilical edema, erythema, and tenderness) in the newborn includes antimicrobial therapy and supportive care. Examine these patients frequently, and immediately debride any tissue that shows signs of advancing infection or necrosis.

Antimicrobial therapy

Note the following:

  • Include parenteral antimicrobial coverage for gram-positive and gram-negative organisms. A combination of an antistaphylococcal penicillin vancomycin 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.

Diet

When omphalitis is associated with systemic symptomatology, do not feed the infant enterally. Enteral feedings may be resumed once the acute infection improves and associated septic ileus resolves. In these infants, parenteral nutrition is required.

Other treatment considerations

Consider the following:

  • 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.

  • For patients who have undergone surgical intervention, postoperatively, inspect the gross appearance of the tissue on the perimeter of the debrided area several times a day or more frequently if the infant has any unresolved signs of systemic infection.

  • Monitor aminoglycoside levels, and adjust the dose accordingly.

  • Monitor and manage metabolic abnormalities, which are common in any ill neonate.

  • 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.

Patient/caregiver education

The American Academy of Pediatrics Committee on Fetus and Newborn guidelines emphasize the importance of parental/caregiver education regarding signs and symptoms of omphalitis. [9]

Referral for psychosocial counseling may assist the family in coping with a critically ill infant. For patient education resources, see Children's Health Center, as well as Umbilical Cord Care.

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Surgical Care

Management of necrotizing fasciitis and myonecrosis involves early and complete surgical debridement of the affected tissue and muscle. [43, 49] Consider the following:

  • 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.

Routine postsurgical follow-up care is indicated. Infants developing portal vein thrombosis require follow-up care for complications associated with portal hypertension.

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Prevention

The World Health Organization (WHO) recommends dry cord care after institutional delivery or after home delivery in locales where neonatal mortality rates are low primarily because there have not been strong studies supporting routine application of topical antiseptic agents. [8, 50] These recommendations for dry cord care in developed countries are supported by large, systematic reviews. [51, 52, 53, 54]

A Cochrane review of 12 trials showed that information regarding the effects of chlorhexidine applied to the umbilical cords of newborns in hospital settings on neonatal mortality is not clear. [53] Two trials had moderate-quality evidence that chlorhexidine cord cleansing reduced the risk of omphalitis/infections compared with dry cord care. Another two trials had low-quality evidence that no difference exists for omphalitis/infections between groups receiving chlorhexidine skin cleansing and dry cord care. However, there was high-quality evidence that chlorhexidine skin or cord care in the community setting led to a 50% reduction in the incidence of omphalitis and a 12% reduction in neonatal mortality. [53] No difference was noted for neonatal mortality or the risk of infections in hospital settings for maternal vaginal chlorhexidine use compared to usual care.

Dry cord care may not be appropriate in certain populations. Because there is increased risk of omphalitis and other serious neonatal infections when delivery occurs in a nonhygienic environment and neonatal mortality is high, application of a topic antiseptic agent to the cord may be indicated. The WHO recommends topical application of chlorhexidine to the umbilical cord stump during the first week of life for neonates born at home where hygienic conditions are poor or neonatal mortality is high (>30 deaths per live births). [8]

Several trials comparing dry cord care to chlorhexidine application have been completed in a variety of settings. [55, 56, 57] In addition, there have been several meta-analyses and/or Cochrane reviews analyzing studies of topical cord care. [51, 52, 53, 55, 58, 59, 60, 61] The interpretations of the results of these trials in aggregate have been controversial, with conclusions on a spectrum from chlorhexidine should be applied universally to no changes to the WHO guidelines are indicated. [62, 63, 64] These various interpretations may be due to a number of factors, including comparisons of different study groups in locales with varying rates of neonatal sepsis, varying end points for the studies, and variation in control groups. However, overall, the recommendations for topical antisepsis cord care in locales where hygienic conditions are poor or neonatal mortality is high are supported by these systematic reviews, [58, 59] noting this intervention significantly reduced the incidence of omphalitis as well as overall neonatal mortality. [56, 60, 61] Optimal dosing strategies for chlorhexidine application are unknown. [58]

In 2016, the American Academy of Pediatrics Committee on Fetus and Newborn guidelines updated their guidelines for umbilical cord care in the newborn. [9] The conclusions of this report were essentially the same as those of the WHO. Application of antimicrobial agents to the cord is appropriate in resource poor settings where the risk of omphalitis and its complications are high, whereas the benefit in high-resource settings is unclear. These guidelines also emphasize the importance of parental education regarding signs and symptoms of omphalitis.

Dry cord care leads to earlier separation of the cord after birth. It also leads to reports of wetter, odoriferous cords (described by some parents as "nasty," "smelly," or "yucky") and higher colonization rates with S aureus and other bacteria (sometimes dramatically so). Whether this increased colonization rate is, or will be, associated with higher rates of omphalitis or other neonatal infection is controversial. Some studies have suggested that higher colonization rates are associated with increased infection, whereas others have not.

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