What is the treatment for omphalitis?

Treatment for Omphalitis

Neonatal omphalitis requires immediate treatment with broad-spectrum intravenous antibiotics, specifically a combination of ampicillin and gentamicin as initial empiric therapy, to cover the most common pathogens including Staphylococcus aureus and gram-negative organisms. 1

Clinical Presentation and Classification

Omphalitis presents with varying degrees of severity, which can be classified into four grades:

1. Funisitis/umbilical discharge (unhealthy-appearing cord with purulent, malodorous discharge)
2. Omphalitis with abdominal wall cellulitis (periumbilical erythema and tenderness)
3. Omphalitis with systemic signs of infection
4. Omphalitis with necrotizing fasciitis (umbilical necrosis with periumbilical ecchymosis, crepitus, bullae, and evidence of involvement of superficial and deep fascia) 2

Treatment Algorithm

Initial Assessment

• Evaluate severity of infection based on the four grades above
• Assess for systemic involvement (fever, lethargy, poor feeding)
• Consider underlying abnormalities (urachal remnants) in cases with persistent drainage 3

Antibiotic Therapy

1. First-line treatment:

   • Combination of IV ampicillin and gentamicin 1
   • Continue for minimum 7-10 days

2. For treatment failure or severe cases:

   • Consider broader coverage with antibiotics effective against resistant organisms
   • Obtain cultures when possible to guide therapy

3. For localized, mild cases in older infants:

   • Consider oral antibiotics in select low-risk cases 3

Surgical Management

• Surgical intervention is indicated for:
  • Development of umbilical abscess requiring drainage
  • Necrotizing fasciitis requiring debridement
  • Peritonitis or intra-abdominal abscess
  • Underlying urachal abnormalities 4

Potential Complications

Omphalitis can lead to serious complications if not promptly treated:

• Portal vein thrombosis
• Periumbilical cellulitis
• Intra-abdominal abscesses
• Peritonitis
• Bowel ischemia
• Necrotizing fasciitis 2, 4

The mortality rate can be as high as 13% without proper treatment, particularly in cases that progress to necrotizing fasciitis or sepsis 1.

Prevention

• In high-resource settings: dry cord care is recommended 2
• In low-resource settings with high neonatal mortality: application of 4% chlorhexidine solution or gel to the umbilical cord stump within 24 hours after birth (reduces omphalitis risk by 52%) 1
• Avoid traditional materials like ash, herbal poultices, or human milk that may introduce pathogens 1

Common Pitfalls and Caveats

1. Delayed recognition: Early identification is crucial as progression can be rapid and potentially fatal
2. Inadequate antibiotic coverage: Ensure coverage for both S. aureus and gram-negative organisms
3. Failure to identify underlying abnormalities: Consider urachal remnants in persistent cases
4. Missing systemic involvement: Monitor closely for signs of sepsis or other serious bacterial infections
5. Inadequate surgical intervention: Necrotizing fasciitis requires prompt and aggressive debridement 4, 5

Remember that while omphalitis is relatively uncommon in developed countries (approximately 1 per 1000 infants with dry cord care), it occurs in up to 8% of infants born in hospitals and up to 22% of infants born at home in low-resource settings 2.