What is the treatment for Omphalitis (inflammation of the umbilical cord stump)?

Treatment of Omphalitis (Umbilical Cord Stump Infection)

The treatment of omphalitis requires prompt antibiotic therapy based on severity, with mild cases (Grade 1) treated with topical antiseptics and moderate to severe cases (Grades 2-4) requiring hospitalization and intravenous antibiotics to prevent potentially life-threatening complications. 1

Clinical Presentation and Severity Assessment

Omphalitis presents with varying degrees of severity that guide treatment decisions:

• Grade 1: Funisitis/umbilical discharge - unhealthy-appearing cord with purulent, malodorous discharge 2
• Grade 2: Omphalitis with abdominal wall cellulitis - periumbilical erythema and tenderness in addition to an unhealthy-appearing cord with discharge 2
• Grade 3: Omphalitis with systemic signs of infection 2
• Grade 4: Omphalitis with necrotizing fasciitis - umbilical necrosis with periumbilical ecchymosis, crepitus, bullae, and evidence of involvement of superficial and deep fascia; frequently associated with signs and symptoms of overwhelming sepsis and shock 2

Treatment Algorithm Based on Severity

Mild Localized Infection (Grade 1)

• Apply topical antiseptics such as aqueous chlorhexidine 0.05% to the infected area 1
• Keep the umbilical area clean and dry 1
• Consider twice-daily application of antiseptics until resolution 1

Moderate to Severe Infection (Grades 2-4)

• Hospitalize the infant immediately 1
• Initiate empiric intravenous antibiotics that cover common pathogens, particularly Staphylococcus aureus, Group A and B Streptococci, and gram-negative organisms (E. coli, Klebsiella, Pseudomonas) 2, 1
• Obtain cultures from purulent discharge to guide antibiotic therapy 3

Severe Infection with Systemic Involvement or Necrotizing Fasciitis (Grades 3-4)

• Provide aggressive fluid resuscitation and supportive care for septic shock 1
• Obtain urgent surgical consultation for possible debridement, especially in cases of necrotizing fasciitis 1, 4
• Monitor closely for complications including intra-abdominal abscesses, periumbilical cellulitis, thrombophlebitis in the portal and/or umbilical veins, peritonitis, and bowel ischemia 2

Antibiotic Selection

• Empiric therapy should cover the most common pathogens, particularly Staphylococcus aureus (including MRSA consideration in endemic areas), Streptococci, and gram-negative organisms 3
• Adjust antibiotics based on culture results and clinical response 5
• Duration of therapy typically ranges from 7-14 days depending on severity and clinical response 5

Local Wound Care

• Keep the umbilical area clean and dry 1
• Consider twice-daily application of antiseptics like chlorhexidine until resolution 1
• Avoid traditional materials that may increase contamination 1
• Consider regular bacterial swabs to monitor infection status 1

Monitoring and Follow-up

• Close monitoring for signs of systemic illness or spreading infection is essential 5
• Consider imaging (ultrasound or CT) if there is concern for deeper infection or abscess formation 6
• Evaluate for possible underlying anomalies such as urachal remnants in cases that do not respond to standard therapy 6

Prevention Strategies

• Proper hand hygiene before handling the umbilical area 1
• Keep cord clean and dry 1
• In high-resource settings, dry cord care is generally recommended 2
• 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 2, 1

Important Considerations and Pitfalls

• Case-fatality rates can be as high as 13% in untreated cases, with higher mortality in necrotizing fasciitis 2, 1
• Avoid delaying treatment in moderate to severe cases as complications can develop rapidly 7
• Consider underlying anomalies in cases that don't respond to standard therapy 6
• Surgical intervention is rarely needed for uncomplicated omphalitis but may be necessary for complications such as abscesses or necrotizing fasciitis 4, 5
• Recent evidence suggests that most omphalitis in high-income countries presents as localized soft tissue infection with low rates of concurrent serious bacterial infection 5