Treatment of Umbilical Stump Infection in Newborns
Umbilical stump infections (omphalitis) require prompt antibiotic treatment, with systemic antibiotics needed for all but the mildest cases, along with proper local wound care to prevent serious complications including sepsis.
Clinical Presentation and Severity Assessment
Omphalitis presents with varying degrees of severity that guide management:
- Grade 1: Funisitis/umbilical discharge - unhealthy-appearing cord with purulent, malodorous discharge 1
- Grade 2: Omphalitis with abdominal wall cellulitis - periumbilical erythema and tenderness plus unhealthy cord with discharge 1
- Grade 3: Omphalitis with systemic signs of infection 1
- Grade 4: Omphalitis with necrotizing fasciitis - umbilical necrosis with periumbilical ecchymosis, crepitus, bullae, and involvement of superficial and deep fascia; often with signs of overwhelming sepsis 1
Treatment Algorithm
1. Mild Localized Infection (Grade 1)
- Apply topical antiseptics such as aqueous chlorhexidine 0.05% to the infected area 1
- Keep the area clean and dry 2
- Monitor closely for progression to more severe infection 3
2. Moderate to Severe Infection (Grades 2-4)
- Hospitalize the infant 1, 3
- Obtain cultures from the umbilical stump before starting antibiotics 3, 4
- Initiate empiric intravenous antibiotics that cover common pathogens (Staphylococcus aureus, group A and B Streptococci, and gram-negative bacilli including E. coli, Klebsiella, and Pseudomonas) 1, 3
- Adjust antibiotics based on culture results and clinical response 3
- Continue antibiotics for 7-10 days depending on severity and response 3
3. Severe Infection with Systemic Involvement or Necrotizing Fasciitis (Grades 3-4)
- Immediate hospitalization in intensive care unit 1
- Aggressive fluid resuscitation and supportive care for septic shock if present 1
- Broad-spectrum intravenous antibiotics (including anaerobic coverage) 1, 3
- Surgical consultation for possible debridement in cases of necrotizing fasciitis 1
- Monitor for complications including intra-abdominal abscesses, periumbilical cellulitis, thrombophlebitis in portal/umbilical veins, peritonitis, and bowel ischemia 1
Local Wound Care
- Keep the umbilical area clean and dry 2
- Regular cleansing with sterile water or saline 2
- Avoid traditional materials (ash, herbal poultices, human milk) that may increase contamination 1, 5
- Consider twice-daily application of antiseptics like chlorhexidine until resolution 1, 6
- Regular bacterial swabs (twice weekly) to monitor infection status 1
Monitoring and Follow-up
- Daily assessment of the umbilical area for:
- Continue treatment until complete resolution of infection 3
Prevention Strategies
- Proper hand hygiene before handling the umbilical area 1
- Keep cord clean and dry 2
- In high-resource settings with low neonatal mortality, dry cord care is generally recommended 1
- In settings with high neonatal mortality, application of 4% chlorhexidine solution or gel to the umbilical cord stump within 24 hours after birth significantly reduces omphalitis risk 1
Important Considerations and Pitfalls
- Do not delay antibiotic treatment while awaiting culture results in moderate to severe cases 3
- Be aware of increasing antibiotic resistance - 86.8% of Enterobacteriaceae isolates show resistance to ampicillin, 13.2% to ceftriaxone, and 10.5% to gentamicin 4
- Consider underlying anomalies (urachal abnormalities) in recurrent or persistent cases 3
- Case-fatality rates can be as high as 13% in untreated cases, with higher mortality in necrotizing fasciitis 1
- Avoid topical agents that may be absorbed systemically in neonates (e.g., silver sulfadiazine, high concentrations of alcohol) 1