What is the treatment for umbilical cellulitis?

Treatment of Umbilical Cellulitis

For umbilical cellulitis without purulent drainage or abscess, initiate oral antibiotics targeting streptococci with penicillin, amoxicillin, cephalexin, dicloxacillin, or clindamycin for 5 days, and hospitalize immediately if systemic signs, necrotizing features, or severe immunocompromise are present. 1

Antibiotic Selection Algorithm

First-Line Oral Therapy (Outpatient)

• Penicillin, amoxicillin, cephalexin, or dicloxacillin are preferred for typical umbilical cellulitis targeting streptococci, the primary pathogen 1
• Amoxicillin-clavulanate provides broader coverage and is appropriate for initial empiric therapy 1
• Clindamycin is the preferred alternative for penicillin-allergic patients, with 99.5% susceptibility against streptococci 2

When to Add MRSA Coverage

• MRSA coverage is not routinely indicated for typical umbilical cellulitis 1
• Consider MRSA coverage only if purulent drainage, penetrating trauma, or underlying abscess is present 1
• If MRSA suspected, add vancomycin (inpatient) or oral clindamycin/trimethoprim-sulfamethoxazole 1

Treatment Duration

• 5 days is sufficient if clinical improvement occurs by day 5 1
• Extend beyond 5 days only if improvement has not occurred 1
• This shorter duration is as effective as traditional 10-day courses when response is adequate 1

Critical Distinction: Cellulitis vs. Abscess

• If purulent collection or abscess is present, this is NOT cellulitis—primary treatment is incision and drainage, not antibiotics alone 1
• The term "cellulitis" should not be used for inflammation surrounding a purulent focus 1
• Recurrent umbilical cellulitis may indicate a foreign body (omphalith), urachal remnant, or other structural abnormality requiring surgical intervention 3, 4

Immediate Hospitalization Criteria

Admit for intravenous antibiotics if any of the following are present:

• Systemic signs: fever, tachycardia, hypotension, confusion, or leukocytosis 1
• Necrotizing features: periumbilical ecchymosis, crepitus, bullae, or rapidly spreading necrosis 1, 5
• Severe immunocompromise or neutropenia 1
• Failure of outpatient therapy within 24-48 hours 1
• Concern for deeper infection: intra-abdominal abscess, portal vein thrombophlebitis, peritonitis, or bowel ischemia 1

Neonatal Considerations

• In neonates, umbilical cellulitis (omphalitis) is caused by Staphylococcus aureus, group A and B Streptococci, and Gram-negative bacilli (E. coli, Klebsiella, Pseudomonas) 1
• Neonatal omphalitis can rapidly progress to necrotizing fasciitis with mortality rates up to 13% 1, 5
• Early recognition and aggressive treatment are critical, as patients may appear deceptively well before rapid deterioration within 24-72 hours 5

Diagnostic Testing

• Blood cultures are unnecessary for typical umbilical cellulitis 1
• Obtain blood cultures if systemic features present (high fever, hypotension), malignancy, neutropenia, or severe immunodeficiency 1
• Consider imaging (ultrasound or CT) if recurrent infection, concern for abscess, or suspicion of urachal remnant 4

Adjunctive Measures

• Elevation of the affected area promotes drainage of edema and inflammatory substances, hastening recovery 1
• Identify and treat predisposing factors: poor hygiene, foreign bodies (omphaliths), or anatomic abnormalities 3, 4

Common Pitfalls to Avoid

• Do not empirically cover MRSA in typical umbilical cellulitis without purulent drainage or specific risk factors 1
• Do not use antibiotics alone if an abscess or purulent collection is present—drainage is mandatory 1
• Do not delay hospitalization if necrotizing features or systemic signs are present, as mortality is high without aggressive early intervention 1, 5
• Do not overlook structural abnormalities in recurrent cases—consider foreign body removal or surgical resection of urachal remnants 3, 4