Treatment of Omphalitis
Omphalitis requires immediate broad-spectrum intravenous antibiotics covering Staphylococcus aureus, Streptococci, and Gram-negative organisms (E. coli, Klebsiella, Pseudomonas), with urgent surgical consultation for any signs of necrotizing fasciitis or systemic complications. 1, 2
Severity-Based Treatment Algorithm
Grade 1: Funisitis/Umbilical Discharge Only
- Mild cases (purulent discharge without periumbilical erythema) may be managed with oral antibiotics in select lower-risk infants, though IV antibiotics remain standard 3
- Close outpatient follow-up within 24 hours is mandatory 3
- Topical antiseptics (4% chlorhexidine) can be applied to the cord stump 1
Grade 2: Omphalitis with Abdominal Wall Cellulitis
- Immediate hospitalization with IV broad-spectrum antibiotics is required 1, 2
- First-line regimen should cover S. aureus (including MRSA consideration), Streptococci, and Gram-negatives 1, 2
- Monitor closely for progression to deeper infection 1
Grade 3: Omphalitis with Systemic Signs
- Aggressive IV antibiotic therapy targeting the most common pathogens: S. aureus, Group A and B Streptococci, E. coli, Klebsiella, and Pseudomonas 1
- Full sepsis workup including blood cultures, complete blood count, and inflammatory markers 2
- Critical pitfall: Concurrent serious bacterial infections (meningitis, urinary tract infection) are rare but must be excluded in systemically ill infants 3
Grade 4: Necrotizing Fasciitis
- This is a surgical emergency with mortality risk requiring immediate aggressive resuscitation, broad-spectrum IV antibiotics, and urgent surgical debridement 1, 4
- Warning signs: Umbilical necrosis, periumbilical ecchymosis, crepitus, bullae, rapid progression, signs of septic shock 1
- Patients may appear deceptively well initially, then deteriorate rapidly within 24-72 hours—early recognition is life-saving 4
- Case-fatality rates for necrotizing fasciitis are significantly higher than other grades 1
Antibiotic Selection
Empiric IV antibiotics should be started immediately upon diagnosis of moderate-to-severe omphalitis (Grades 2-4) 2, 3:
- Coverage must include S. aureus (most common pathogen), Streptococci, and Gram-negative bacilli 1, 2
- Consider vancomycin plus an anti-pseudomonal beta-lactam (piperacillin-tazobactam or ceftazidime) for severe cases 2
- Anaerobic coverage (metronidazole or clindamycin) should be added if necrotizing fasciitis is suspected 2, 4
Important caveat: Many cultures may be sterile if antibiotics were given before presentation, but this should not delay empiric treatment 2
Surgical Intervention
Indications for urgent surgical consultation 2, 4:
- Necrotizing fasciitis (requires radical debridement) 2, 4
- Spontaneous evisceration through umbilical cicatrix (occurs in 26% of complicated cases) 2
- Intra-abdominal or hepatic abscesses 2
- Superficial abscesses requiring drainage 2
- Peritonitis 2
Monitoring for Complications
Life-threatening complications can develop rapidly and include 1, 2:
- Intra-abdominal abscesses
- Portal or umbilical vein thrombophlebitis
- Peritonitis and bowel ischemia
- Necrotizing fasciitis extending to scrotum/genitalia (26% of complicated cases) 2
- Intestinal obstruction from adhesions 2
Mortality considerations: Case-fatality rates up to 13% have been reported for omphalitis overall, with significantly higher rates for necrotizing fasciitis 1
Prevention Context
While prevention is not treatment, understanding risk factors helps identify high-risk patients 1: