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Omphalitis

Omphalitis is a polymicrobial infection of the umbilical stump in neonates. Pathogenicity ranges from localized cellulitis to systemic disease. Omphalitis is a leading cause of infant mortality in less developed countries where provisions for proper healthcare services are inadequate.


Presentation

During the early stage of the disease the infant exhibits difficulty with feeding, later becoming increasingly irritable, lethargic or somnolent as infection spreads. Acquisition of anaerobic bacteria from the mother's genital tract or from septic delivery accounts for higher incidence of omphalitis in infants with amnionitis, premature or prolonged rupture of membranes. Furthermore, presence of urine or feces in the umbilicus indicates a coexisting abnormal anatomic condition.

The initial manifestations of localized infection are: presence of foul-smelling pus from the umbilical stump; reddening of skin of the periumbilical area, with or without pus; edema; and tenderness.

Extensive local disease is characterized by necrotizing fasciitis or myonecrosis, spreading from the periumbilical area to adjacent regions of the abdominal wall and into the scrotum, and multiple infection with aerobic and anaerobic organisms. Other signs and symptoms are: petechiae, ecchymoses, crepitus, peau d'orange appearance, bullae, and progression of cellulitis despite antimicrobial therapy, possibly due to antibiotic resistance.

Multiorgan involvement leads to sepsis and systemic disease with resulting complications. These are: thermoregulation dysfunction (hyperthermia/hypothermia) [4]; cardiovascular signs (hypotension, tachycardia, delayed capillary refill (< 2-3 s); respiratory distress (hypoxemia, apnea, tachypnea, grunting, flaring of the nasal alae, intercostal or subcostal retractions); GI tract disturbances (abdominal distention/rigidity, absent bowel sounds); cutaneous signs (cyanosis, petechiae, jaundice); and neurologic abnormalities (neurasthenia, poor feeding, hypotonia/hypertonia).

Hyperthermia
  • These are: thermoregulation dysfunction (hyperthermia/hypothermia); cardiovascular signs (hypotension, tachycardia, delayed capillary refill ( 2-3 s); respiratory distress (hypoxemia, apnea, tachypnea, grunting, flaring of the nasal alae, intercostal[symptoma.com]
Aspiration
  • Criteria 1 - all of the following: (1) age (2) erythema and/or serous drainage from umbilicus (3) at least one of the following: (3a) organism isolated from culture of drainage (3b) organism isolated from culture of needle aspirate (3c) organism isolated[meducator3.net]
  • Hepatic abscess, identified by ultrasound or CT scan is aspirated, guided by imaging, and the abscess cavity is washed clean with normal saline. Treat with parenteral antibiotics and repeat aspiration and drainage if needed.[symptoma.com]
  • Management Culture of discharge will often reveal normal colonizing bacteria and there are no studies to show the value of aspirating the leading edge of the cellulitis. Antibioitcs must cover Staph. aureus and Strep. pyogenes.[pedclerk.bsd.uchicago.edu]
Periumbilical Pain
  • A significant decrease in periumbilical pain, elimination of the disturbing chronic discharge, and vaporization of the reactive granulation tissue were achieved, suggesting this technique as an attractive option in the treatment of chronic recidivant[ncbi.nlm.nih.gov]
Periumbilical Pain
  • A significant decrease in periumbilical pain, elimination of the disturbing chronic discharge, and vaporization of the reactive granulation tissue were achieved, suggesting this technique as an attractive option in the treatment of chronic recidivant[ncbi.nlm.nih.gov]
Absent Bowel Sounds
  • bowel sounds); cutaneous signs (cyanosis, petechiae, jaundice); and neurologic abnormalities (neurasthenia, poor feeding, hypotonia/hypertonia).[symptoma.com]
Abdominal Wall Edema
  • Rapidly progressive anterior abdominal wall edema and cellulitis were noted in 16 patients who were clinically diagnosed with necrotizing fasciitis. Fifteen of these patients died soon after emergence of anterior abdominal wall edema and cellulitis.[ncbi.nlm.nih.gov]
Grunting
  • These are: thermoregulation dysfunction (hyperthermia/hypothermia); cardiovascular signs (hypotension, tachycardia, delayed capillary refill ( 2-3 s); respiratory distress (hypoxemia, apnea, tachypnea, grunting, flaring of the nasal alae, intercostal[symptoma.com]

Workup

Blood cultures: for the isolation and identification of  microorganisms.

CBC count with manual differential. Neutrophilia or neutropenia indicates acute infection. Consider systemic bacterial infection with an immature-to-total neutrophil ratio greater than 0.2 and thrombocytopenia.

Other nonspecific laboratory tests may include the following: neutrophil CD64, procalcitonin, C-reactive protein, erythrocyte sedimentation rate, and Limulus lysate test (detects endotoxin).

Confirmatory tests for sepsis and disseminated intravascular coagulation (DIC) are: peripheral blood smear, fibrinogen, D-dimer, prothrombin time, and activated partial thromboplastin time.

Imaging studies include: abdominal radiography to detect presence of intra-abdominal wall gas; ultrasonography and CT scan, showing anatomic abnormalities [11], fascial thickening and fluid in tissues.

Treatment

The goal of treatment in omphalitis is elimination of the causative organisms through antibiotic therapy. Prompt and adequate administration of antimicrobial drugs is important. In uncomplicated cases treatment for Staphyloccocus aureus infection and an aminoglycoside effective against gram-positive and gram-negative organisms is sufficient. The results of susceptibility tests should guide the choice of antibiotic drugs. Combinations of ampiclox, cloxacillin, flucloxacillin, methicillin, and gentamycin are recommended, with metronidazole for anaerobes. Short-term treatment of 7 days is appropriate in uncomplicated cases or 10-14 days with parenteral administration for complicated cases.

Administration of intravascular fluids and transfused blood/plama/platelets or cyroprecipitate are recommended in case of complications such as hypotension, disseminated intravascular coagulation and respiratory failure.

Treatment of Surgical Complications

Morbidity and mortality in omphalitis depend on onset and duration of surgical complications. Therefore, medical intervention for omphalitis should be based on comprehensive treatment of surgical complications.

Necrotising Fasciitis

Necrotising fasciitis (NF) is a major concern in 26% of complicated cases [12]. It has been reported in 13.5% of omphalitis in neonates, presenting with periumbilical cellulitis. Deferred treatment may lead to necrosis of the skin and subcutaneous tissue, or worse yet, myonecrosis. NF of the scrotum is common. The abdominal wall is likewise affected. Periumbilical cellulitis should be treated early with parenteral broad-spectrum antibiotics including metronidazole. Remove dead or degenerated tissues by debridement and replace wound dressing everyday. Parenteral or rectal paracetamol may be substituted for general anesthesia for severely ill infant. Large wounds may be sutured later or replaced with skin graft except scrotal wound [13].

Evisceration

Evisceration of the small and large intestines may occur as a late complication. The exposed intestine should be covered with a moist gauze and placed in an appropriate protective bag with care that it is not twisted. After cleaning under anesthesia, it is installed in its proper place in the peritoneal cavity while the umbilicus is repaired. Laparotomy may be required in cases with peritonitis or gangrene to drain abscesses and to clean the peritoneal cavity. Gangrenous intestine is extricated and the separated loops are reconnected.

Peritonitis

Peritonitis without abdominal abscess open link may not require surgery and infection can be controlled with broad-spectrum intravenous antibiotics. Intraperitoneal abscess as confirmed by ultrasonography or laparotomy should be drained and cleaned thoroughly.

Abscesses

Intraperitoneal abscess or those located in the anterior abdominal wall and other locations should be drained at laparotomy, or accessed extraperitoneally if situated retroperitoneally [14]. Hepatic abscess, identified by ultrasound or CT scan is aspirated, guided by imaging, and the abscess cavity is washed clean with normal saline. Treat with parenteral antibiotics and repeat aspiration and drainage if needed.

Prognosis

Timely interventions of uncomplicated cases save lives. Multiple infections, if left untreated can result in mortality rates as high as 7-15% [9]. Complications have been associated with necrotizing fasciitis peritonitis, evisceration, and portal vein thrombosis [10]. Thirty-eight to eighty-seven percent deaths were linked to necrotizing fasciitis and myonecrosis. Poor prognosis is attributed to unhygienic birthing practices, male and preterm babies.

Etiology

The umbilical cord is a suitable "culture media" for bacterial growth and proliferation. It becomes ischemic, deteriorates as the stump dries up and detaches from the abdominal skin. Meanwhile, bacterial pathogens may colonize exposed cord tissue. Infection can involve the umbilical blood vessels, abdominal wall lymphatics and blood vessels, and surrounding areas. Several species of bacteria have been identified as causative agents. The pathogenicity of omphalitis is determined by the location and severity of infection of the affected site. Current practices in postnatal and cord care, antibiotic susceptibility/resistance, and health status of neonates influence the outcome of treatment of omphalitis.

A single species or a combination of both aerobic and anaerobic microbial species have been isolated from omphalitis cases.

Aerobic organisms include [5] [6]:

Anaerobic species, associated with about 30% of cases are:

Epidemiology

Between 2 to 7 cases of omphalitis per 100 live births have been reported in developing countries compared to 0.2-0.7% in developed countries [2]. More cases are found in places where aseptic practices in home-based birthing services do not exist. In one African study, omphalitis was reported in 28% newborns admitted to the pediatric ward. In the hospital setting, 2-54 infants in 1000 live births are estimated to be susceptible to omphalitis.

Although more cases seen were males, there is no predilection for racial origin. The mean age of onset of symptoms depends on the gestational age as follows: 3–5 days for preterm infants; 5–9 days for term infants; 5-75 days (ave. 33 days), for those with complications.

Unclean methods in handling the umbilical cord and the stump account for widespread omphalitis in Africa. As part of the culture, substances such as engine oil, cow dung, talc powder, or palm oil are applied on the stump after cutting the cord with any old implement without antiseptic. The mother is unwashed and birthing is done without the necessary precautions against infection. Infants who are born in the hospital may be subject to septic umbilical catheterisation.

Other risk factors are: prolonged rupture of membranes; debilitated, premature, underweight, or immunodeficient neonates; genetic defects related to contractile proteins during parturition; leukocyte adhesion deficiency (LAD) syndrome; and defect in neutrophil mobility.

Sex distribution
Age distribution

Pathophysiology

The umbilical cord is the lifeline of the fetus to the mother in utero. It is cut immediately after birth leaving a stump with its rich supply of blood vessels and connective tissue. As such, the cord is readily invaded by microbial pathogens during and after birthing. Bacteria attract polymorphonuclear leukocytes to the umbilical cord as a natural body defense mechanism [8]. Separation of the stump from the abdominal skin is preceded by a cascade of events from inflammation, mobilization of phagocytic leukocytes, obstruction of blood supply, dessication, and necrosis, with the participation of collagenase and proteases.

Colonization of the umbilical stump with aerobic and anerobic species of pathogenic bacteria causes omphalitis. In the absence of hygienic methods in birthing and cord care the microbial populations will build up and invade subcutaneous tissues. Omphalitis may present as localized cellulitis or progress to more severe disease entities such as: necrotizing fasciitis, necrosis of abdominal wall muscles. or phlebitis. Factors leading to the exacerbation of omphalitis under these conditions remain to be ascertained.

Prevention

Hygienic birthing practices and proper care of the umbilical cord is the key to prevention of omphalitis in neonates. Antibiotic therapy will eliminate microbial infection and possible complications.

The following list of prophylactic/antiseptic regimens until cord separation are recommended:

  • Daily application of triple dye [15], or triple dye applied once and daily dousing with alcohol, or triple dye applied once, without antibiotics
  • Daily application of povidone-iodine
  • Daily application of silver sulfadiazine
  • Bacitracin ointment applied daily
  • Chlorhexidine [7] 4% applied once, without antibiotics, or chlorhexidine 4% applied daily
  • Concoction of salicylic sugar powder (97% powdered sugar, 3% salicylic acid) applied daily

Routine topical therapy is practiced in developing countries to prevent widespread incidence of omphalitis.

Summary

The umbilical cord is composed of two arteries and one vein enclosed by mucilaginous connective tissue (called Wharton's jelly) and a thin mucoid membrane [1]. Normally after birth inflammation at the proximal end of the cord will cause the umbilical stump to detach from the abdominal skin. This natural process is accompanied by whitish slimy material that is mistaken for pus. The cord may be odorous. Separation should occur within 5-15 days post partum. Cesarean section, infection and improper application of antiseptic can deter this process [1].

Umbilical stump that fails to detach on time may be infected, with pus and erythema of surrounding area, or intense redness beyond 2 cm from the stump, with or without pus [2]. Risk factors are: prolonged labor, maternal infection, prematurity, low birth weight (<2500 gm), septic delivery, delayed rupture of membrane, umbilical catheterization, and male gender [3]. The infant may be febrile, lethargic, have difficulty feeding and with distended abdomen. Neonatal sepsis is common[4]. Mortality rates vary with gestational age and as much as 30% deaths have been attributed to low birth weight.

Several species of both aerobic and anaerobic bacteria acquired during and after delivery are the causes of infection. High mortality rates are associated with unclean cord care and widespread infection. Treatment should be based on the identification of the causative microorganisms and results of antibiotic susceptibility tests. Hygienic birthing practices are the mainstays of prevention.

Patient Information

Omphalitis is bacterial infection of the umbilical stump in newborn babies due to unclean delivery practices and improper cord care. It is initially manifested by redness and swollen skin around the umbilical stump. If left untreated, the microorganisms multiply and spread to other organs causing severe illness or systemic disease.

Causes

Eighty-five percent (85%) of omphalitis cases are caused by several species of bacteria. The most common among these are gram-positive cocci e.g., Staphylococcus aureus, group A streptococci and gram-negative enteric bacilli e.g., Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. The widespread use of triple dye for antistaphylococcal cord care has promoted the proliferation of gram-negative organisms in omphalitis. Infection with anaerobic species, Bacteroides fragilis and Clostridium perfringens, have been isolated in one third of cases, causing necrotizing fasciitis or myonecrosis. Clostridium tetani and Clostridium sordellii have been associated in deliveries done outside a medical facility and with the tradition of applying cow dung on the umbilical stump.

Symptoms

The clinical course of omphalitis depends on antenatal, delivery and postnatal health care. For instance, feeding difficulty may be an indication of infection, accompanied by irritability or lethargy. Decreased level of activity may result from systemic dissemination of the infection. Contamination with anaerobic bacteria from the female genital tract during delivery and from maternal infections during pregnancy contribute to susceptibility of infants with untimely rupture of membranes and amnionitis. Anatomic aberration is indicated with finding of urine or stool from the umbilicus.

Diagnosis

A normal umbilical stump initially appears bluish-white and moist. It becomes black and dries up before falling off within days or weeks, leaving a pinkish wound that heals completely. An infected umbilical stump presents with superficial cellulitis. Redness and slight bleeding may occur in normal stump when cleaning with caustic agents or when silver nitrate is used to cauterize granulomata of the umbilical stump. Rarely. Leukocyte Adhesion Deficiency, an autosomal recessive disease, may occur with CD18 deficiency.

Treatment

Early recognition of symptoms is important and omphalitis should be treated as a medical emergency. The choice of appropriate antimicrobials can not be overemphasized. Complicated cases may require surgical intervention.

References

Article

  1. Mullany LC, Darmaetadt GL, Katz J et al. Risk factors for umbilical cord infection among newborn of southern Nepal. Am J Epidemiol 2007 Jan 15; 165(2): 203-211.
  2. Cushing AH. Omphalitis: a review. Pediatr Infect Dis. 1985 May-Jun. 4(3):282-5.
  3. Sawardekar KP. Changing spectrum of neonatal omphalitis. Pediatr Infect Dis J 2004;23:22-26.
  4. Philip AG. The changing face of neonatal infection: experience at regional medical centre. Pediatr Infect Dis 1994; 13: 1098-1102.
  5. Airede AI. Pathogens in neonatal omphalitis. J Trop Pediatr. 1992 Jun. 38(3):129-31. 
  6. Brook I. Microbiology of necrotizing fasciitis associated with omphalitis in the newborn infant. J Perinatol. 1998 Jan-Feb. 18(1):28-30.
  7. McClure EM, Goldenberg RL, Brandes N, Darmstadt GL, Wright LL. The use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-income settings. Int J Gynaecol Obstet 2007; 97:89–94. 
  8. Janhavi S, Prerna R, Michael H, et al. Polymorphonuclear leukocytes isolated from umbilical cord blood as a useful research tool to study adherence to cell monolayers. J Immunol Methods. 2009 Dec 31; 351(1-2): 30–35. 
  9. Ameh EA, Nmadu PT. Major complications of omphalitis in neonates and infants. Pediatr Surg Int 2002; 18:413–416.
  10. Winani S, Wood S, Coffey P, Chirwa T, et al. Use of clean delivery kit and factors associated with cord infection and puerperal sepsis in Mwanza, Tanzania. J Midwifery Womens Health 2007; 52:37–43.
  11. Song Y, Xu D, Sun L, et al. Diagnosis and management of primary umbilical melanoma with omphalitis features. Case Rep Oncol. 2013 Mar 21;6(1):154-7.
  12. Winani S, Wood S, Coffey P, Chirwa T, Mosha F, Changalucha J. Use of clean delivery kit and factors associated with cord infection and puerperal sepsis in Mwanza, Tanzania. J Midwifery Womens Health. 2007; 52:37–43.
  13. Ameh EA, Dauda MM, Sabiu L, Mshelbwala PM, Mbibu HN, Nmadu PT. Fournier’s gangrene in neonates and infants. Eur J Pediatr Surg 2004; 14:418–421.
  14. Feo CF, Dessanti A, Franco B, Ganau A, Iannaccelli M. Retroperitoneal abscess and omphalitits in young infants. Acta Paediatr 2003; 92:122–125.
  15. Panyavudhikrai S, Danchaivijitr S, Vantanasiri C, et al. Antiseptics for preventing omphalitis. J Med Assoc Thai. 2002 Feb;85(2):229-34. 

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Last updated: 2019-07-11 22:36