Omphalitis is an infection of the umbilical stump.[1] Omphalitis typically presents as a superficial cellulitis that may spread to involve the entire abdominal wall and may progress to necrotizing fasciitis, myonecrosis, or systemic disease. Omphalitis is uncommon in industrialized countries; however, it remains a common cause of neonatal mortality in less developed areas. Omphalitis is predominantly a disease of the neonate. Only a few cases have been reported in adults. Approximately three fourths of omphalitis cases are polymicrobial in origin. Aerobic bacteria are present in approximately 85% of infections, predominated byStaphylococcus aureus, group A Streptococcus, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis.[2, 3] In the past, studies emphasized the importance of gram-positive organisms (eg, S aureus and group A Streptococcus) in the etiology of omphalitis. This was followed by a series of reports that highlighted the role of gramnegative organisms in the etiology of omphalitis. These studies suggested that the change in etiology may have been caused by the introduction of prophylactic umbilical cord care using antistaphylococcal agents, such as hexachlorophene and triple dye (a widely adopted practice in the 1960s), with a subsequent increase in gram-negative colonization of the umbilical stump. Monitoring the microbial etiology of omphalitis is important, as recent trends have moved back to dry cord care without routine application of topical antiseptic agents. This trend has been widely accepted and is supported by the American Academy of Pediatrics (AAP), which supports dry cord care of the umbilicus after birth. 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, sometimes dramatic, colonization rates with S aureus and other bacteria. 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. Discontinuation of routine application of topical agents may not be prudent in certain populations. A study from Nepal demonstrated that early chlorhexidine application reduced omphalitis and overall neonatal mortality;[4]a study from Germany had similar results,[5] and a study of infants in Bangladesh is underway.[6] When techniques adequate for the recovery of anaerobic bacteria are used in studying newborns with omphalitis, anaerobes are recovered from one to two thirds of patients.[7, 8] [9] The predominant anaerobic isolates include Bacteroides fragilis,Peptostreptococcus species, and Clostridium perfringens. Several mothers whose newborns had omphalitis caused by B fragilis also had amnionitis caused by this organism. Isolated cases due to other anaerobic organisms, including Clostridium sordellii, also are reported. Neonatal tetanus (with or without omphalitis) caused byClostridium tetani usually results from contamination of the umbilical cord during improperly managed deliveries outside of a medical facility or the cultural practice of placing cow dung on the umbilical stump after delivery. Neonatal tetanus is rare in the United States but is common in developing countries.

13] Mortality/Morbidity Outcome is usually favorable in infants with uncomplicated omphalitis associated with cellulitis of the anterior abdominal wall. data are limited and conclusions cannot be drawn regarding the role of these factors in the mortality rate. no deaths occurred among 32 infants with omphalitis in the absence of necrotizing fasciitis and myonecrosis. The image below shows the anatomic relationship between the umbilicus and its embryologic attachments. in which devitalized tissue provides a medium that supports bacterial growth.[14] The mortality rate among all infants with omphalitis. however.Pathophysiology The umbilical stump represents a unique but universally acquired wound. the infection may progress beyond the subcutaneous tissues to involve fascial planes (necrotizing fasciitis). abdominal wall musculature (myonecrosis). prematurity or being small for gestational age.[11. Suggested risk factors for poor prognosis include male sex. 12. and the umbilical and portal veins (phlebitis). Episodes of omphalitis are reported and are usually sporadic. rarely. . leading to omphalitis. is estimated at 7-15%.[10] Incidence is higher in hospitalized preterm infants than in full-term infants. Epidemiology Frequency International Overall incidence varies from 0. Anatomic relationship between the umbilicus and its embryologic attachments. epidemics occur (eg. including those who develop complications. The mortality rate is significantly higher (38-87%) after the development of necrotizing fasciitis or myonecrosis. These bacteria have the potential to invade the umbilical stump. Normally.7% in industrialized countries. and septic delivery (including unplanned home delivery). due to S aureus or group A Streptococcus). If this occurs. the cord area is colonized with potential bacterial pathogens during or soon after birth. but. The factors that cause colonization to progress to infection are not well understood. In a study by Sawin and colleagues.2-0.

. sepsis. Proceed to Clinical Presentation History A detailed review of the pregnancy. algorithms that attempt to standardize the clinical diagnosis of omphalitis have been developed.) o Edema o Tenderness The image below shows a case of omphalitis associated with bullous impetigo due to Staphylococcus aureus. emphasizing extent of periumbilical erythema and absence or presence of pus.    A history of poor feeding or feeding intolerance may be an early indication of infection. such as premature or prolonged rupture of membranes and amnionitis. and the neonatal course is important when assessing omphalitis. Physical The following may be associated with omphalitis:  Local disease: Physical signs vary with the extent of disease. intra-abdominal complications. labor. or a history of a decreased level of activity may be an important indicator of systemic dissemination of the infection. In preterm infants. and somnolence.Sequelae of omphalitis may be associated with significant morbidity and mortality. History of urine or stool discharge from the umbilicus suggests an underlying anatomic abnormality. A history of change in mental status. and death (see Complications). such as irritability. the higher incidence of omphalitis caused by anaerobes (especially B fragilis) in infants with adverse perinatal histories. the mean age at onset is 5-9 days. myonecrosis. Age In full-term infants. may relate to exposure to maternal infection. lethargy. Sex No sex predilection has been reported. delivery. Anaerobic bacteria are part of the normal flora of the female genital tract and are commonly involved in ascending infections of the uterus and in septic complications of pregnancy. septic embolization. therefore. the mean age at onset is 3-5 days. although males may have a worse prognosis than females. Signs of localized infection include the following: o Purulent or malodorous discharge from the umbilical stump o Periumbilical erythema (Recently. including necrotizing fasciitis.

or delayed capillary refill (< 2-3 s) o Respiratory disturbances . petechiae.  Systemic disease: Signs of sepsis or other systemic disease are nonspecific and include disturbances of thermoregulation or evidence of dysfunction of multiple organ systems. or cyanosis o Neurologic abnormalities . intercostal or subcostal retractions. flaring of the alae nasi. or temperature instability o Cardiovascular disturbances .Apnea.Irritability. or hypertonia Causes . violaceous discoloration o Bullae o Peau d'orange appearance o Crepitus o Petechiae o Progression of cellulitis despite antimicrobial therapy The images below demonstrate findings in a case of omphalitis (left) associated with extensive myonecrosis (right). or hypoxemia o GI tract disturbances . tachypnea (respirations >60/min). lethargy. which are typically found in a periumbilical location but may spread across the abdominal wall.Jaundice. weak sucking.Tachycardia (pulse >180 beats per minute [bpm]).  Extensive local disease.Rigid or distended abdomen or absent bowel sounds o Cutaneous abnormalities . Examples include the following: o Disturbances of thermoregulation .Fever (temperature >38°C). hypothermia (temperature < 36°C). onto the flanks and back. grunting. and into the scrotum. hypotension (systolic blood pressure < 60 mm Hg in full-term infants). These signs may also suggest infection by both aerobic and anaerobic organisms and include the following: o Ecchymoses.A case of omphalitis associated with bullous impetigo due to Staphylococcus aureus. A case of omphalitis (left) associated with extensive myonecrosis (right). with extension: The following signs indicate more extensive local disease. hypotonia. such as necrotizing fasciitis or myonecrosis.

An immature-to-total neutrophil ratio greater than 0. and meningitis. 24. [21. 17. sepsis.      Associated risk factors include the following: Low birth weight (< 2500 g) Prior umbilical catheterization Septic delivery (as suggested by premature rupture of membranes. obtain specimens from the involved muscle rather than the wound surface. the underlying immune-mediated neutrophil destruction may not be immediately appreciated in affected newborns. 30. an anatomic abnormality such as a patent urachus. 18.2 may be a useful indicator of systemic bacterial infection in the first few days of life.Omphalitis is a polymicrobial infection typically caused by a mixture of aerobic and anaerobic organisms. 29. 23. pneumonia. If myonecrosis is suspected. Affected infants may present with other cutaneous infections. 26] Infants with neonatal alloimmune neutropenia or congenital neutropenia have presented with omphalitis. Neonatal alloimmune neutropenia is a disease analogous to Rh-hemolytic disease and results from maternal sensitization to fetal neutrophils bearing antigens that differ from the mother's. a rare immunologic disorder with an autosomal recessive pattern of inheritance. 19. 31] o o o Laboratory Studies The following studies are indicated in omphalitis:  Routinely obtain specimens from umbilical infection and submit specimens for Gram stain and culture for aerobic and anaerobic organisms.  Obtain blood cultures for aerobic and anaerobic organisms. Omphalitis may complicate congenital neutropenia. nonsterile delivery. Rarely. patent omphalomesenteric duct. 20] Numerous infants with acute or chronic omphalitis have been diagnosed with LAD. with or without omphalitis o Recurrent infections Omphalitis may also be the initial manifestation of neutropenia in the neonate.[16. o Thrombocytopenia may be present. or maternal infection) o Prolonged rupture of membranes Omphalitis occasionally manifests from an underlying immunologic disorder. 25.  Obtain a CBC count with manual differential. 22. 28. The congenital neutropenias are a disease group of heterogenous disorders that range from intermittent to persistent manifestations of varying severity. Maternal immunoglobulin G antibodies cross the placenta and result in an immune-mediated neutropenia that can be severe and last for several weeks to 6 months. Because omphalitis complicated by sepsis can also be associated with neutropenia. These infants typically present with the following: o Leukocytosis o Delayed separation of the umbilical cord. o Neutrophilia or neutropenia may be present in acute infection. . or urachal cyst may be present.[15] Leukocyte adhesion deficiency (LAD) is most prominent among the immunodeficiency syndromes.[27.

have been evaluated for their usefulness in rapid detection of bacterial infection in neonates. CT scanning of the abdomen may determine the presence and extent of muscle and/or fascial involvement and potentially aid in detection of anatomic abnormalities. which detects endotoxin  The following laboratory studies are suggested in neonates in whom sepsis and disseminated intravascular coagulation (DIC) are suspected: o Peripheral blood smear o Prothrombin time o Activated partial thromboplastin time o Fibrinogen o Fibrinogen split products or D-dimer  Other abnormalities associated with serious systemic infection include the following: o Hypoglycemia o Hypocalcemia (often related to saponification with fatty acids released by bacterial lipases in subcutaneous tissue) o Metabolic acidosis Imaging Studies The following imaging studies may be indicated:    Abdominal radiography may reveal intra-abdominal wall gas.  Antimicrobial therapy . It may also be useful in the detection of anatomic abnormalities. many of which are no longer viable. although none has demonstrated sensitivity or specificity sufficiently high to dictate clinical care. Other nonspecific laboratory tests. Medical Care Treatment of omphalitis (periumbilical edema. Ultrasonography may reveal fascial thickening and fluid accumulation between subcutaneous fat and muscle in cases with fascial involvement. either alone or in combination with a defined scoring system. The tests include the following: o C-reactive protein levels o Procalcitonin o Erythrocyte sedimentation rate o Neutrophil CD64 o Limulus lysate test. and tenderness) in the newborn includes antimicrobial therapy and supportive care. or myonecrosis. Histologic Findings Analysis of biopsy specimens may reveal necrotizing fasciitis. erythema. which is an acute inflammatory process surrounding muscle bundles. which is an acute inflammatory infiltrate found in subcutaneous fat and connective tissue. Procedures Lumbar puncture may be warranted in infants in whom sepsis is suspected.

o Administer fluid. with antimicrobial therapy directed at anaerobic organisms as well as gram-positive and gram-negative organisms. or both (as indicated) for hypotension. o 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. Failure to respond may suggest disease progression. o Additional topical therapy with triple dye. In the treatment chambers. A combination of an antistaphylococcal penicillin vancomycin and an aminoglycoside antibiotic is recommended.  Other treatment considerations o Monitor patients for progression of disease. presence of an anatomic defect. o Administration of platelets. Early surgical intervention may be lifesaving. expect erythema of the umbilical stump to improve within 12-24 hours after the initiation of antimicrobial therapy. particularly patterns of S aureus and enterococcal susceptibility. tissue levels of oxygen are maximized when the patient breathes 100% oxygen at 2-3 atm. excision of preperitoneal tissue (including . or an immunodeficiency state. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach. but such treatment is unproven. o Treat infants at centers capable of supporting cardiopulmonary function. consider local antibiotic susceptibility patterns.Include parenteral antimicrobial coverage for gram-positive and gram-negative organisms. o In uncomplicated cases. and other antimicrobials has been suggested in addition to parenteral antibiotic therapy. o As with antimicrobial therapy for other infections. o Surgical Care Management of necrotizing fasciitis and myonecrosis involves early and complete surgical debridement of the affected tissue and muscle. 33]  Although the extent of debridement depends on the viability of tissue and muscle. fresh frozen plasma. These measures include the following: o Provide ventilatory assistance and supplementary oxygen for hypoxemia or apnea unresponsive to stimulation. bacitracin. Metronidazole or clindamycin may provide anaerobic coverage.[32. vasoactive agents. 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.  Supportive care: In addition to antimicrobial therapy. o Pseudomonas species have been implicated in particularly rapid or invasive disease. which is determined at the time of surgery. and initiation of hyperbaric oxygen therapy should not delay transport to a facility with staff capable of performing surgical debridement. surgical therapy has the highest priority. or cryoprecipitate for disseminated intravascular coagulation (DIC) and clinical bleeding is suggested. supportive care is essential to survival. o Some believe that anaerobic coverage is important in all patients.

umbilical vessels. sodium bicarbonate) may be required for supportive care. and urachal remnant) is critically important in the eradication of the infection. Used in combination both with an agent against gram-positive organisms and with an agent that covers anaerobes.   the umbilicus. Medication Summary A combination of parenterally administered antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended for uncomplicated omphalitis. packed RBCs. do not feed the infant enterally. Antibiotics Class Summary Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. These tissues can harbor invasive bacteria and provide a route for progressive spread of infection after less extensive debridement. Consultations The following consultations may be indicated:   Infectious disease specialist . Some believe that anaerobic coverage also should be considered in all infants with omphalitis. Enteral feedings may be resumed once the acute infection resolves. Delay in diagnosis or surgery allows progression and spread of necrosis. is suggested. Parenteral nutrition is required in infants with omphalitis. and antimicrobial therapy directed at anaerobic organisms. fresh frozen plasma) and other medications (eg. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach.For appropriate antimicrobial selection. . As with antimicrobial therapy for other infections. Blood products (eg. consider local antibiotic susceptibility patterns and results of blood and biopsy specimen culturing. leading to extensive tissue loss and worsening systemic toxicity. Several surgical procedures may be required before all nonviable tissue is removed.If necrotizing fasciitis or myonecrosis is suspected (consult early in the disease course) Diet Once omphalitis is suspected.[34] View full drug information Gentamicin (Garamycin) Aminoglycoside antibiotic for gram-negative coverage. as well as gram-positive and gram-negative organisms. particularly if necrotizing fasciitis or myonecrosis occurs Surgeon . Metronidazole may be added to the combination of antistaphylococcal penicillin and aminoglycoside to provide anaerobic coverage. or clindamycin may be substituted for antistaphylococcal penicillin. platelets. inotropic agents.

Especially important in the treatment of MRSA. Listeria. View full drug information Metronidazole IV (Flagyl) Anaerobic antibiotic that also has amebicide and antiprotozoal actions. Vancoled) Bacteriocidal agent against most aerobic and anaerobic gram-positive cocci and bacilli. and meningococci. Further Inpatient Care Examine the patient with omphalitis frequently. some strains of Haemophilus influenzae.    Postoperatively. Further Outpatient Care Routine postsurgical follow-up care is indicated. and adjust dose accordingly. causing bactericidal activity against susceptible organisms. View full drug information Vancomycin (Vancocin. Also effective against aerobic and anaerobic streptococci (except enterococci). which are common in any ill neonate. such as GBS. Bactericidal for organisms. possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. 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. View full drug information Clindamycin (Cleocin) Used to treat infections caused by anaerobic bacteria. Monitor and manage metabolic abnormalities. Bactericidal antibiotic that inhibits cell wall synthesis. Monitor aminoglycoside levels. and immediately debride any tissue that shows signs of advancing infection or necrosis. Interferes with bacterial cell wall synthesis during active replication. Recommended therapy when coagulase-negative staphylococcal sepsis is suspected. Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. . Inhibits bacterial growth. non–penicillinase-producing staphylococci. Infants developing portal vein thrombosis require follow-up care for complications associated with portal hypertension.View full drug information Oxacillin (Bactocill) Antistaphylococcal penicillin. May be used to initiate therapy when staphylococcal infection is suspected. Used in the treatment of infections caused by penicillinase-producing staphylococci. View full drug information Ampicillin Broad-spectrum penicillin.

peritonitis. aminoglycoside. septic embolization. Complications The sequelae of omphalitis may be associated with significant morbidity and mortality. including the following: Triple dye applied once daily until cord separation Triple dye applied once. 42. may require transfer to an ICU equipped to treat infants. Topical therapy is also commonly used in attempts to control outbreaks of omphalitis. are administered during hospitalization. Transport the patient with advanced life support technology in place and qualified personnel in attendance. and clindamycin or metronidazole if indicated. then no further antimicrobial treatment Povidone-iodine applied daily until cord separation Silver sulfadiazine applied daily until cord separation Bacitracin ointment applied daily until cord separation Chlorhexidine 4% applied once. spontaneous evisceration. endocarditis and liver abscess formation. enzymatic destruction of supporting connective tissue.[35. . 40. and destruction of host humoral and cellular immune responses to infecting organisms. These include necrotizing fasciitis. myonecrosis. 39. including those who may require surgical intervention. abdominal or retroperitoneal abscess). bowel obstruction.Inpatient & Outpatient Medications Intravenous antimicrobial therapy with an antistaphylococcal penicillin. 33. particularly. subcutaneous fat. and. 37]  Necrotizing fasciitis: This is a florid bacterial infection of the skin. Transfer Critically ill infants. o Necrotizing soft tissue infections are caused by production of factors (by single or multiple organisms) that lead directly to tissue cell death. Options for further treatment or intervention must be immediately available. 3% salicylic acid) applied daily until cord separation Routine topical therapy may be indicated in developing countries where omphalitis is more common. (SeeTransport of the Critically Ill Newborn.) Deterrence/Prevention Antimicrobial agents have been applied to the umbilicus to decrease bacterial colonization and to prevent omphalitis and associated complications. with no further antimicrobial treatment Chlorhexidine 4% applied daily until cord separation Salicylic sugar powder (97% powdered sugar.  o o o o o o o o o   Several effective umbilical cord care regimens are available. and superficial and deep fascia that complicates 8-16% of cases of neonatal omphalitis. abdominal complications (eg. 43] It is characterized by rapidly spreading infection and severe systemic toxicity. 41.[38. and death. 36. Necrotizing fasciitis typically involves the abdominal wall but may also involve the scrotum or penis. sepsis. then alcohol applied daily until cord separation Triple dye applied once.

bacteremia was a complication in 13% of infants with omphalitis. and skin. the Eh of healthy muscle is 120-160 mV. bowel obstruction. Because of progressive deep tissue destruction and subsequent systemic spread of toxins.     Certain organisms are well known to invade tissue and proliferate in necrotic areas. in particular. the aerobic organisms use oxygen available in tissue. 47] o Prognosis The prognosis for infants with omphalitis varies. In infections with mixtures of facultative aerobes and anaerobes. liver. S aureus. and may limit host defenses and penetration of systemic antimicrobial agents. which constricts the muscle within its fascia. including the heart. rapid development of edema. C perfringens. Patient Education Referral for psychosocial counseling may assist the family in coping with a critically ill infant. Group A Streptococcus. disseminated intravascular coagulation (DIC) and multiple organ failure may occur. o In infants with omphalitis. In a study by Mason and colleagues. may facilitate movement of organisms through soft tissue planes. Also. extrahepatic portal hypertension. peritonitis. and biliary obstruction. poor blood supply. abdominal abscess. Abdominal complications: Abdominal complications include spontaneous evisceration. visit eMedicineHealth's Children's Health Center. Sepsis: This is the most common complication of omphalitis. 46. anaerobic infections. thereby further reducing the Eh in tissues inoculated by Clostridium species or other anaerobic bacteria. Long-term or late complications of omphalitis: These may include nonneoplastic cavernous transformation of the portal vein. retroperitoneal abscess. and established infection by aerobic bacteria such as staphylococci or streptococci.[45. lungs. For excellent patient education resources. or liver abscess. allowing anaerobic bacterial growth. in particular. often to less than 150 mV. may lead to ischemic myonecrosis.[3] Myonecrosis: This refers to infectious involvement of muscle. foreign material. o The toxins produced in the anaerobic environment of necrotic tissue allow rapid spread of organisms through tissue planes. Local spread of toxins extends the area of tissue necrosis. portal vein thrombosis. development of myonecrosis usually depends on conditions that facilitate the growth of anaerobic organisms. . does not replicate under conditions of an oxidationreduction potential (Eh) greater than -80 mV. kidneys. and Clostridiumspecies may elaborate extracellular enzymes and toxins that can damage tissue. see eMedicineHealth's patient education article Umbilical Cord Care. These conditions include the presence of necrotic tissue. may be fatal if not treated promptly. In these infants. pancreas. In addition.[44] Septic embolization: If septic embolization arises from infected umbilical vessels. it may lead to metastatic foci in various organs. allowing continued growth of organisms and increasing elaboration of toxins.

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