Omphalitis: Background, Pathophysiology, Epidemiology http://emedicine.medscape.

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Omphalitis
Updated: Jan 02, 2016
Author: Patrick G Gallagher, MD; Chief Editor: Ted Rosenkrantz, MD more...

OVERVIEW

Background
Omphalitis is an infection of the umbilical stump. [1] It typically presents as a superficial cellulitis that
can spread to involve the entire abdominal wall and may progress to necrotizing fasciitis,
myonecrosis, or systemic disease. Omphalitis is uncommon in industrialized countries; however, it
remains a common cause of neonatal mortality in less developed areas. It is predominantly a
disease of the neonate, with only a few cases having been reported in adults.

Approximately three fourths of omphalitis cases are polymicrobial in origin. Aerobic bacteria are
present in approximately 85% of infections, predominated by Staphylococcus aureus, group A
Streptococcus, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. [2, 3] In the past,
studies emphasized the importance of gram-positive organisms (eg, S aureus and group A
Streptococcus) in the etiology of omphalitis. This was followed by a series of reports that
highlighted the role of gram-negative organisms in the etiology of omphalitis. These studies
suggested that the change in etiology may have been caused by the introduction of prophylactic
umbilical cord care using antistaphylococcal agents, such as hexachlorophene and triple dye (a
widely adopted practice in the 1960s), with a subsequent increase in gram-negative colonization of
the umbilical stump.

In addition to monitoring trends in incidence, monitoring the microbial etiology of omphalitis is

important, as recent trends have moved back to dry cord care, without routine application of topical
antiseptic agents. This trend has been widely accepted, including by the American Academy of
Pediatrics (AAP). [4] Similarly, the World Health Organization (WHO) currently recommends dry
cord care, primarily because there have not been strong studies supporting routine application of
topical antiseptic agents. [5, 6] These recommendations for dry cord care in developed countries are
supported by large, systematic reviews. [5, 7] The exception in developed countries may be after
home delivery, where topical application of an antiseptic agent to the umbilical cord may be
indicated. [8, 9]

Dry cord care leads to earlier separation of the cord after birth. It also leads to reports of wetter,
odoriferous cords (described by some parents as nasty, smelly, or yucky) and higher colonization
rates with S aureus and other bacteria (sometimes dramatically so). Whether this increased
colonization rate is, or will be, associated with higher rates of omphalitis or other neonatal infection
is controversial. Some studies have suggested that higher colonization rates are associated with
increased infection, whereas others have not.

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Omphalitis: Background, Pathophysiology, Epidemiology http://emedicine.medscape.com/article/975422-overview

Dry cord care may not be appropriate in certain populations. Because there is increased risk of
omphalitis and other serious neonatal infections when delivery occurs in a nonhygienic
environment, application of a topic antiseptic agent to the cord may be indicated. The WHO
recommends topical application of chlorhexidine to the umbilical cord stump during the first week of
life for neonates born at home in high neonatal mortality settings (ie, those with at least 30 neonatal
deaths per 1000 live births). [6] Meta-analysis of topical application of chlorhexidine to the umbilical
cord of children born in underdeveloped countries under nonhygenic conditions revealed that this
intervention significantly reduced the incidence of omphalitis, as well as overall neonatal mortality.
Optimal dosing strategies for chlorhexidine application are unknown. [8]

A Cochrane review of 12 trials showed that information regarding the effects of chlorhexidine
applied to the umbilical cords of newborns in hospital settings on neonatal mortality is not clear. [10]
Two trials had moderate-quality evidence that chlorhexidine cord cleansing reduced the risk of
omphalitis/infections compared with dry cord care. Another two trials had low-quality evidence that
no difference exists for omphalitis/infections between groups receiving chlorhexidine skin cleansing
and dry cord care. However, there was high-quality evidence that chlorhexidine skin or cord care in
the community setting led to a 50% reduction in the incidence of omphalitis and a 12% reduction in
neonatal mortality. [10] No difference was noted for neonatal mortality or the risk of infections in
hospital settings for maternal vaginal chlorhexidine use compared to usual care.

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