Omphalitis is a topic covered in the Select 5-Minute Pediatrics Topics.

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Basics

Description

Omphalitis, an infection of the umbilical stump, begins in the neonatal period as a superficial cellulitis but may progress to necrotizing fasciitis, myonecrosis, or systemic disease.

Epidemiology

  • Episodes of omphalitis are usually sporadic, but rare epidemics occur.
  • Mean age of onset is 5–9 days in term infants and 3–5 days in preterm infants.
  • Incidence varies from 0.2 to 0.7% of live births in developed countries and up to 21% of live births in developing countries.

Risk Factors

  • Low birth weight
  • Prior umbilical catheterization
  • Septic delivery
  • Male sex

General Prevention

  • There are multiple methods used for umbilical cord care, many of which are acceptable.
  • Antimicrobial agents applied to the umbilicus may decrease bacterial colonization and prevent omphalitis, particularly in developing countries.
  • Effective methods of umbilical cord care:
    • Clean, dry cord care (AAP/WHO recommended)
    • Triple dye
    • Topical 4% chlorhexidine
    • 70% alcohol solution
  • There is significant evidence to support the use of topical 4% chlorhexidine to prevent omphalitis in developing countries, although it does delay time to cord separation.
  • There is no evidence that application of an antiseptic to the umbilical cord is better than clean, dry cord care in a hospital setting.

Pathophysiology

  • Potential bacterial pathogens normally colonize the umbilical stump after birth.
  • These bacteria invade the umbilical stump, leading to omphalitis.
  • Established aerobic bacterial infection, necrotic tissue, and poor blood supply facilitate the growth of anaerobic organisms.
  • Infection may also extend beyond the subcutaneous tissues to involve fascial planes (fasciitis), abdominal wall musculature (myonecrosis), and umbilical and portal veins (phlebitis).

Etiology

  • Most cases of omphalitis are polymicrobial.
  • The most common organisms include gram-positive cocci (Staphylococcus aureus, group A streptococci) and gram-negative enteric bacilli (Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis).
  • Gram-positive organisms predominate; however, antistaphylococcal cord care has led to an increase in colonization and infection with gram-negative organisms.
  • Anaerobic bacteria, including Bacteroides fragilis and Clostridium perfringens, are most likely in cases complicated by necrotizing fasciitis or myonecrosis.
  • Clostridium tetani and Clostridium sordellii are seen primarily in developing countries when cow dung is used in cord care.

Commonly Associated Conditions

  • Leukocyte adhesion deficiency
    • Omphalitis may be the initial manifestation of one of the leukocyte adhesion deficiencies (LADs).
    • LADs are rare, autosomal recessive immunologic disorders affecting leukocyte adhesion to blood vessel walls.
    • Cord separation requires the influx of leukocytes; therefore, this deficiency causes delayed separation and can cause concomitant omphalitis.
    • Infants also may present with leukocytosis, absence of pus formation, impaired wound healing, and recurrent infections localized to the skin and mucosal surfaces.
    • Treatment involves prompt recognition of infection and use of appropriate antibiotics. Severe cases may need hematopoietic stem cell transplantation.
  • Neutropenia
    • Omphalitis complicated by sepsis can be associated with neutropenia.
    • Other syndromes of neonatal neutropenia may present initially with omphalitis.
      • Neonatal alloimmune neutropenia: Maternal IgG antibodies cross the placenta and cause immune-mediated destruction of fetal neutrophils bearing antigens differing from mother’s.
      • Other causes of neutropenia: autoimmune neutropenias, X-linked agammaglobulinemia, hyper-IgM immunodeficiency syndromes, HIV, glycogen storage disease type IB, or disorders of amino acid metabolism
  • Anatomic abnormalities
    • Patent urachus: The urachus, a tubular structure connecting the bladder to the umbilicus, should obliterate by the 5th gestational month. If it remains patent, a continuous, significant amount of urine can drain from the umbilicus.
    • Persistent omphalomesenteric duct: congenital malformation where a communication exists between the umbilicus and the gut. Drainage consists of intestinal secretions.
    • Excessive granulation tissue: results from delayed healing of cord stump. Drainage is serosanguinous and pink.
  • Considerations in preterm infants:
    • Preterm infants are more susceptible secondary to immature immune defenses (including the skin) and possible umbilical catheterization.
    • These infants are more likely to present with omphalitis at an earlier age and with low neutrophil counts.

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Citation

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TY - ELEC T1 - Omphalitis ID - 14035 Y1 - 2015 PB - Select 5-Minute Pediatrics Topics UR - https://im.unboundmedicine.com/medicine/view/Select-5-Minute-Pediatric-Consult/14035/all/Omphalitis ER -