What is the treatment for an infected umbilical (navel) cord?

Treatment of Infected Umbilical Cord (Omphalitis)

Hospitalize the infant immediately and initiate empiric intravenous antibiotics covering Staphylococcus aureus, Streptococci, and Gram-negative organisms (E. coli, Klebsiella, Pseudomonas) for any infection beyond simple discharge, as mortality can reach 13% and complications include sepsis, necrotizing fasciitis, and portal vein thrombosis. 1, 2

Severity Grading and Treatment Algorithm

The American Academy of Pediatrics classifies omphalitis into four grades that directly determine treatment intensity 1, 2:

Grade 1: Funisitis/Umbilical Discharge Only

• Presentation: Unhealthy-appearing cord with purulent, malodorous discharge without surrounding skin involvement 1, 2
• Treatment: Apply topical antiseptics such as aqueous chlorhexidine 0.05% twice daily to the infected area 2
• Monitoring: Keep area clean and dry; obtain bacterial swabs to identify pathogens 2
• Escalation criteria: If no improvement within 24-48 hours or any signs of spreading infection, escalate to systemic antibiotics 2

Grade 2: Omphalitis with Abdominal Wall Cellulitis

• Presentation: Periumbilical erythema and tenderness plus unhealthy cord with discharge 1, 2
• Treatment: Hospitalize and initiate IV antibiotics immediately 2
• Antibiotic coverage: Must cover S. aureus (most common pathogen), Group A and B Streptococci, E. coli, Klebsiella, and Pseudomonas 1
• Local care: Continue twice-daily chlorhexidine application alongside systemic therapy 2

Grade 3: Omphalitis with Systemic Signs

• Presentation: Signs of sepsis including fever, lethargy, poor feeding, tachycardia, or respiratory distress 1, 2
• Treatment: Aggressive IV antibiotics plus fluid resuscitation and supportive care for septic shock 2
• Monitoring: Blood cultures, complete blood count, C-reactive protein; monitor for complications including intra-abdominal abscesses, peritonitis, and portal/umbilical vein thrombophlebitis 1

Grade 4: Necrotizing Fasciitis

• Presentation: Umbilical necrosis with periumbilical ecchymosis, crepitus, bullae, involvement of superficial and deep fascia, overwhelming sepsis 1, 2
• Treatment: Immediate surgical consultation for debridement, aggressive fluid resuscitation, broad-spectrum IV antibiotics, and intensive care support 2
• Prognosis: This grade carries the highest mortality risk and requires emergent intervention 1

Empiric Antibiotic Selection

Target the most common pathogens identified in neonatal omphalitis: 1

• S. aureus remains the most frequently reported organism 1
• Gram-negative bacilli (E. coli, Klebsiella, Pseudomonas) are common, particularly in dry cord care settings where E. coli colonization occurs in 34% of cases 3
• Group A and B Streptococci are significant pathogens 1
• Anaerobic organisms occur rarely but should be considered in severe cases 1

Local Wound Care Principles

• Keep the umbilical area clean and dry at all times 2
• Apply chlorhexidine 0.05% twice daily until complete resolution of infection 2
• Avoid traditional materials or substances that may increase contamination risk 2
• Do NOT use silver sulfadiazine or high-concentration alcohol due to systemic absorption risks in neonates 2
• Obtain bacterial swabs regularly to monitor pathogen clearance and guide antibiotic therapy 2

Critical Complications Requiring Vigilance

The umbilical cord provides direct vascular access to the bloodstream, creating risk for life-threatening complications 1:

• Intra-abdominal abscesses 1
• Portal vein thrombophlebitis 1
• Umbilical vein thrombophlebitis 1
• Peritonitis 1
• Bowel ischemia 1
• Sepsis and septic shock 1, 2

Common Pitfalls to Avoid

• Underestimating mild-appearing infections: Even Grade 1 omphalitis can progress rapidly to systemic infection; maintain low threshold for hospitalization 1, 2
• Delaying antibiotic therapy: Case-fatality rates reach 13% in untreated cases, with higher mortality in necrotizing fasciitis 1, 2
• Using inappropriate topical agents: Avoid agents with systemic absorption potential in neonates 2
• Inadequate follow-up: Community health nurses observed significantly more exudate (7.4%) and foul odor (2.9%) in dry care settings, emphasizing need for vigilant monitoring 3
• Missing risk factors: Unplanned home birth, low birth weight, prolonged rupture of membranes, umbilical catheterization, and chorioamnionitis all increase omphalitis risk 6-fold 1