What is the management for a patient with bloody, foul-smelling discharge from the umbilicus?

Management of Bloody, Foul-Smelling Umbilical Discharge

Cleanse the umbilical area immediately with an antiseptic solution such as povidone-iodine and initiate systemic antibiotics if there are signs of periumbilical erythema, tenderness, or systemic infection. 1

Initial Assessment

Examine for severity grading to guide treatment intensity:

• Grade 1 (Funisitis): Unhealthy-appearing umbilicus with purulent, malodorous discharge only 2
• Grade 2: Periumbilical erythema and tenderness extending beyond the immediate umbilical area 2
• Grade 3: Systemic signs of infection including fever, lethargy, or poor feeding 2
• Grade 4: Necrotizing fasciitis with umbilical necrosis, periumbilical ecchymosis, crepitus, or bullae 2

The bloody, foul-smelling nature of the discharge indicates bacterial infection, most commonly caused by Staphylococcus aureus, group A and B Streptococci, or Gram-negative bacilli including E. coli, Klebsiella, and Pseudomonas species. 2, 1

Treatment Algorithm

For Mild Localized Infection (Grade 1)

• Apply topical antiseptics such as aqueous chlorhexidine 0.05% to the infected area twice daily until resolution 3
• Keep the umbilical area clean and dry between applications 1, 3
• Do NOT apply topical antibiotic ointments or creams, as these promote fungal infections and antimicrobial resistance 2, 1

For Moderate to Severe Infection (Grades 2-4)

• Hospitalize immediately and initiate empiric intravenous antibiotics covering S. aureus, Streptococci, and Gram-negative bacilli 3
• Provide aggressive fluid resuscitation if systemic signs are present 3
• Obtain surgical consultation for possible debridement if necrotizing fasciitis is suspected 3

Local Wound Care

• Cleanse with povidone-iodine (avoid tincture of iodine due to potential thyroid effects in neonates) 2, 1
• Consider twice-daily application of chlorhexidine antiseptic until complete resolution 3
• Obtain bacterial swabs to identify the causative organism and guide antibiotic therapy 3

Special Considerations for Umbilical Catheters

If an umbilical catheter is present:

• Remove immediately if any signs of catheter-related bloodstream infection, vascular insufficiency, or thrombosis are present 2, 4
• Do not replace the catheter once removed in the setting of infection 2

Critical Pitfalls to Avoid

• Never use topical antibiotic ointments (Category IA recommendation against use) 2, 1
• Avoid traditional materials or substances that may increase contamination 3
• Do not delay systemic antibiotics if periumbilical cellulitis or systemic signs are present, as case-fatality rates can reach 13% in untreated omphalitis, with higher mortality in necrotizing fasciitis 3, 5
• In adults presenting with umbilical discharge, consider imaging (ultrasound or CT) to evaluate for urachal remnants or intra-abdominal complications including abscesses, peritonitis, or portal vein thrombophlebitis 2, 6