What is the diagnosis and treatment for omphalitis (inflammation of the umbilicus)?

From the Guidelines

Omphalitis should be treated with prompt intravenous antibiotics, such as ampicillin and gentamicin, and local wound care, including cleaning with sterile saline or mild antiseptic solutions like chlorhexidine, to reduce the risk of morbidity and mortality. The diagnosis of omphalitis is based on clinical signs and symptoms, including redness, swelling, and foul-smelling discharge from the umbilical cord stump. According to a study published in Pediatrics in 2016 1, omphalitis can occur in up to 8% of infants born in hospitals and in as many as 22% of infants born at home, with moderate to severe cases associated with sepsis in 2% of cases.

Treatment

• Intravenous antibiotics, such as ampicillin (150-200 mg/kg/day divided every 6 hours) and gentamicin (4-5 mg/kg/day divided every 24 hours), are recommended for 7-10 days to treat omphalitis 1.
• For more severe cases with systemic symptoms, clindamycin (30-40 mg/kg/day divided every 8 hours) may be added to cover anaerobic bacteria.
• Local wound care is essential, including cleaning the area with sterile saline or mild antiseptic solutions like chlorhexidine and keeping the area dry.

Prevention

• Proper hand hygiene and keeping the cord stump clean and dry can help prevent omphalitis.
• Applying chlorhexidine in settings with high infection risk, such as in low-income communities, can significantly reduce the risk of omphalitis and neonatal mortality, with a relative risk of 0.48 (95% confidence interval: 0.40-0.57) 1.

Signs of Complications

• Increasing redness, swelling, foul-smelling discharge, bleeding, or if the baby develops fever or appears ill require immediate medical attention.
• Prompt treatment is crucial as the infection can rapidly progress to sepsis due to the rich blood supply in the area and the immature immune system of newborns.

From the Research

Diagnosis of Omphalitis

• Omphalitis is diagnosed based on clinical presentation, which includes erythema and induration around the umbilical stump, and purulent drainage may be present 2
• Fever and signs of systemic illness may occur, or there may only be signs of localized soft tissue infection 2
• Underlying urachal abnormalities should be considered in the infant with umbilical drainage 2
• Cord swabs can be taken for culture and susceptibility tests to determine the causative organism and appropriate antibiotic treatment 3

Treatment of Omphalitis

• Treatment of omphalitis consists primarily of antibiotic administration, with surgical intervention rarely needed 2
• Antibiotics are typically administered intravenously, but there may be a role for oral antibiotics in some lower risk infants with omphalitis 2
• Debridement and supportive care may also be necessary in some cases 4
• Antiseptics, such as triple dye, can be used to prevent omphalitis, especially in epidemic outbreaks 5

Causative Organisms and Antibiotic Resistance

• Staphylococcal aureus is the most common cause of omphalitis, followed by other organisms such as Neisseria spp, E. coli, and Proteus spp 3
• There is a high resistance to commonly used antibiotics, such as ampicillin, gentamicin, and cloxacillin, among isolates from neonates with omphalitis 3
• Clinicians should perform cord swabbing for culture and susceptibility tests before initiating antibiotic treatment to ensure appropriate therapy 3

Complications of Omphalitis

• Omphalitis can lead to serious complications, such as necrotising fasciitis, which can be fatal if not recognized and treated promptly 4, 6
• Umbilical sepsis is a rare but potentially catastrophic complication of omphalitis, and prompt recognition and management are crucial for survival 6