What is the best treatment approach for a 50-year-old male with foul-smelling discharge from his umbilicus (navel) without signs of systemic infection, such as fever (afebrile) or elevated white blood cell count (leukocytosis), and should topical antibiotics like mupirocin be considered?

Management of Umbilical Discharge in an Afebrile Patient

For a 50-year-old male with foul-smelling umbilical discharge without fever or leukocytosis, topical mupirocin 2% ointment applied three times daily for 5-7 days is the recommended treatment approach.

Assessment of Umbilical Infection

The patient presents with:

• Foul-smelling discharge from the umbilicus (belly button)
• Duration of symptoms: 1.5 weeks
• No fever (afebrile)
• No elevated white blood cell count (no leukocytosis)

This clinical picture suggests a localized infection of the umbilicus without systemic involvement, most likely representing a superficial skin infection or possibly an umbilical abscess.

Treatment Approach

First-Line Treatment:

• Topical mupirocin 2% ointment applied to the affected area three times daily 1
• Apply a small amount directly to the umbilicus and surrounding area
• Treatment duration: 5-7 days

Rationale for Topical Antibiotics:

1. Mupirocin has excellent activity against gram-positive bacteria (staphylococci and streptococci), which are common pathogens in superficial skin infections 2, 3
2. The FDA-approved mupirocin ointment is indicated for minor skin infections and secondarily infected skin lesions 1
3. Localized infections without systemic symptoms (fever, leukocytosis) can be appropriately managed with topical therapy 4
4. Mupirocin has been shown to be as effective as oral antibiotics for superficial skin infections in multiple studies 5

Wound Care Instructions:

• Clean the umbilical area with warm water and mild soap before each application
• Gently dry the area thoroughly before applying the medication
• Consider using a gauze dressing if there is significant discharge
• Avoid tight clothing over the area to allow air circulation

Monitoring and Follow-up

• Clinical response should be expected within 3-5 days 1
• If no improvement occurs within this timeframe, the patient should be re-evaluated for:
  • Deeper infection requiring systemic antibiotics
  • Possible foreign body in the umbilicus
  • Need for incision and drainage if an abscess is present
  • Alternative diagnoses (e.g., umbilical granuloma, urachal cyst)

When to Consider Systemic Antibiotics

Systemic antibiotics should be considered if:

1. Patient develops systemic symptoms (fever, elevated white blood cell count)
2. Infection extends beyond the umbilical area with significant surrounding cellulitis
3. No improvement after 3-5 days of topical therapy
4. Evidence of deeper tissue involvement

Important Caveats

• Petroleum-based skin protectants may be equally effective for minor skin irritations without true infection 6
• Prolonged use of topical antibiotics may result in overgrowth of nonsusceptible organisms, including fungi 1
• If the discharge persists despite appropriate treatment, further investigation may be warranted to rule out deeper structural problems or foreign bodies

Alternative Diagnoses to Consider

If treatment fails, consider alternative diagnoses:

• Umbilical granuloma
• Urachal sinus or cyst
• Foreign body
• Pilonidal disease of the umbilicus
• Sebaceous cyst infection

The absence of systemic symptoms supports the use of topical therapy as first-line treatment, with close monitoring for clinical improvement.