Omphalitis

Omphalitis?
An infection of the umbilicus and or the umbilical stump or
surrounding tissues- the infection can spread to the subcutis or along
the abdominal wall causing necrotizing fasciitis, myonecrosis and
systemic infection

N.B
May be the manifestation of underlying immunological disorder-e.g.
leukocyte adhesion deficiency, alloimmune neutropenia-such babies
present with-delayed separation of cord, recurrent infections, and
leukocytosis/leukopenia
Funisitis?-Inflammation of the umbilical cord
 Epidemiology
 Less than 1% in developed countries
 Estimated at 0-7% in developing countries BUT data is either lacking or incomplete
 Risk for omphalitis 6X higher for home delivery compared to hospital delivery
 85% poly microbial
 7-87% mortality
 100% mortality at NDUTH Okolobiri-unpublished data
 Risk factors
 Low birth weight
 Prolonged rupture of membranes
 Home delivery
 Complicated delivery
 Improper cord care-severed with unsterile tools at delivery, use of dry/wet heat
fomentation at birth, use of tooth paste, ”survival leaf”, cow dung.
 Umbilical catheterization
 Pathophysiology
Colonization of umbilicus (dead devitalized tissue makes good growth medium)-
bacteria invades umbilicus(omphalitis)-invade fascial planes(necrotizing fasciitis)-
invade abdominal wall musculature(myonecrosis)-invade umbilical and portal
veins(phlebitis)-blood stream dissemination-sepsis +portal vein thrombosis +septic
embolization+endocarditis

Incubation period
Preterm Baby-3-5 days
Term Baby-5-9 days

N.B. What causes progression from simple colonization to tissue invasion is not
known
 Causative organisma
 Staphylococcus aureus
 Grp A streptococcus
 Escherichia Coli
 Klebsiella pneumoniae
 Proteus mirabilis
 Bacteroides fragillis
 Clostridium spp-perfringens, sordellii, tetanus
 Presentation
Local
 Painful umbilical and peri-umbilical swelling
 Erythema, dark discoloration-if gangrene has set in, at umbilicus and surrounding tissues
 Purulent/malodourous discharge from umbilicus-differential-patent urachus or omphalomesenteric cyst
 Bullae
 Crepitus-gas forming organism-clostridia
CNS
 Irritability, lethargy, weak or poor suck, hypo/hyper-tonia, CVA
CVS
 Poor peripheral perfusion CRT>2 seconds
 Tachycardia
 Hypotension
Omphalitis
 Presentation
RS
 Tachypnea
 Respiratory Distress-flaring, chest indrawing, grunting
 Apnea
 Respiratory failure
GIT
 Abdominal rigidity
 ileus
Hematological
 Pallor , jaundice-from hemolysis or hypoperfusion
 DIC
Metabolic
 Hypoglycemia
 Hypocalcemia-saponification of necrotic fat
 Metabolic acidaemia
Investigations
 Swab site or discharge and send for both gram stain, aerobic and anaerobic culture if there is
myonecrosis-take specimen from affected site
 Blood Culture-aerobic and anaerobic
 FBC-leukocytosis Leukopenia, Neutrophilia, Neutropenia, Neutrophil I:T Ratio > 0.2 suggests sepsis
 LFT- Liver enzymes and PT, aPTT, FDP, Fibrinogen-
 Abdo X-Ray and CT-intra abdominal wall gas and to determine extent of myonecrosis respectively
 Differentials
 Patent Urachus
 Omphalomesenteric Cyst
 Umbilical Granuloma
 Immunological Disorder-leukocyte dysfunction/neutrophil dysfunction
 Treatment
1. 1 Supportive
2. 2 Specific
 Supportive Treatment
 Hypotension-fluid resuscitation, inotropic support
 Ventilatory failure- Ventilatory support
 DIC/Coagulopathy-platelet transfusion, FFP, Cryoprecipitate since
 Specific Treatment
Antibiotic choice should be based on empirical local microbial sensitivity patterns. Combination therapy
with appropriate antistaphylococcal, good anti gram-negative and anaerobic cover
 Antistahpylococcal-cloxacillin, fluclocacillin, sulbactam+ampicillin, amoxicillin+clavunalate,
vancomycin, linezolid
 Antigram negative-gentamicin, cefuroxime, ceftriaxone, ceftazidime-greenish colored discharge or
Azlocillin, Ticarcillin; Cefotaxime, Cefixime
 Anaerobes-Metronidazole
 ATS-risk for tetanus
 Surgical consult for debridement
 Prevention and Reduction of Mortality
 Health Education
 Health promotion
 Prevention and appropriate management of preterm and LBW deliveries when they occur
 Prevention of septic deliveries and adoption of appropriate cord care practices-Chlorhexidine
gel
 P
 Chlorhexidine Scale up Strategy
 Sepsis and Neonatal Pneumonia account for > 50% of Neonatal deaths
 Sepsis from infected umbilical cord stump is one of the major routes for infection and death
 WHO recommends use of Chlorhexidine for cord care for home births in areas where
NMR>30/1000 live births-Current NMR Nigeria-37/1000
 Evidence shows that applying topical chlorhexidine can reduce all-cause Neonatal Mortality by
23%
 Chlorhexidine is a bisbiguanide compound with broad spectrum anti-microbial properties-active
against grampositive and gram negative microbes –it disrupts the bacterial cell membrane
 Chlorhexidine-easy to produce-Drugfield alone can produce 20 million 25 gram tubes in one shift-
(Emzor and Tuyil also licensed)
 4% Chlorhexidine gel in 25gram tubes for multiple application from within 2 hours of birth then
daily till cord drops off or gel finishes
 Risk factors for poor prognosis
 Prematurity
 Male gender
 SGA
 Septic delivery