Omphalitis
Encyclopedia
Omphalitis is the medical term for infection of the umbilical cord
stump in the neonatal newborn period. While currently an uncommon anatomical location for infection
in the newborn in the United States
, it has caused significant morbidity and mortality both historically and in areas where health care
is less readily available.
l infection
s, omphalitis is more common in those patients who have a weakened or deficient immune system
or who are hospitalized and subject to invasive procedures. Therefore, infants who are premature, sick with other infections such as blood infection (sepsis
) or pneumonia
, or who have immune deficiencies
are at greater risk. Infants with normal immune systems are at risk if they have had a prolonged birth
, birth complicated by infection of the placenta (chorioamnionitis
), or have had umbilical catheter
s.
Clinically, neonates with omphalitis present within the first two weeks of life with signs and symptoms of infection (cellulitis
) around the umbilical stump (redness, warmth, swelling, pain), pus
from the umbilical stump, fever
, fast heart rate (tachycardia
), low blood pressure (hypotension
), somnolence, poor feeding, and yellow skin (jaundice
). Omphalitis can quickly progress to sepsis
and presents a potentially life-threatening infection. In fact, even in cases of omphalitis without evidence of more serious infection such as necrotizing fasciitis
, mortality is high (in the 10% range).
and Streptococcus
, Escherichia coli
, and Klebsiella pneumoniae
. The infection is typically caused by a mix of these organisms and is a mixed Gram-positive
and Gram-negative
infection. Anaerobic
bacteria can also be involved.
. There may be some confusion, however, if a well-appearing neonate simply has some redness around the umbilical stump. In fact, a mild degree is common, as is some bleeding at the stump site with detachment of the umbilical cord. The picture may be clouded even further if caustic agents have been used to clean the stump or if silver nitrate
has been used to cauterize
granuloma
ta of the umbilical stump.
Leukocyte Adhesion Deficiency is a rare (autosomal recessive disease) in which there is an absence of CD18.
therapy aimed at the typical bacterial pathogen
s in addition to supportive care for any complications which might result from the infection itself such as hypotension
or respiratory failure
. A typical regimen will include intravenous antibiotics such as from the penicillin-group
which is active against Staphylococcus aureus
and an aminoglycoside
for activity against gram-negative bacteria. For particularly invasive infections, antibiotics to cover anaerobic bacteria may be added (such as metronidazole
). Treatment is typically for two weeks and often necessitates insertion of a central venous catheter
or peripherally inserted central catheter
.
/birthing center
has its own recommendations for care of the umbilical cord
after delivery. Some recommend not using any medicinal washes on the cord. Other popular recommendations include triple dye, betadine
, bacitracin
, or silver sulfadiazine. There is little data to support any one treatment (or lack thereof) over another.
Umbilical cord
In placental mammals, the umbilical cord is the connecting cord from the developing embryo or fetus to the placenta...
stump in the neonatal newborn period. While currently an uncommon anatomical location for infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
in the newborn in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, it has caused significant morbidity and mortality both historically and in areas where health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
is less readily available.
Epidemiology
The current incidence in the United States is somewhere around 0.5% per year. There does not appear to be any racial or ethnic predilection.Clinical manifestations
Like many bacteriaBacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
l infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
s, omphalitis is more common in those patients who have a weakened or deficient immune system
Immune system
An immune system is a system of biological structures and processes within an organism that protects against disease by identifying and killing pathogens and tumor cells. It detects a wide variety of agents, from viruses to parasitic worms, and needs to distinguish them from the organism's own...
or who are hospitalized and subject to invasive procedures. Therefore, infants who are premature, sick with other infections such as blood infection (sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
) or pneumonia
Pneumonia
Pneumonia is an inflammatory condition of the lung—especially affecting the microscopic air sacs —associated with fever, chest symptoms, and a lack of air space on a chest X-ray. Pneumonia is typically caused by an infection but there are a number of other causes...
, or who have immune deficiencies
Immunodeficiency
Immunodeficiency is a state in which the immune system's ability to fight infectious disease is compromised or entirely absent. Immunodeficiency may also decrease cancer immunosurveillance. Most cases of immunodeficiency are acquired but some people are born with defects in their immune system,...
are at greater risk. Infants with normal immune systems are at risk if they have had a prolonged birth
Birth
Birth is the act or process of bearing or bringing forth offspring. The offspring is brought forth from the mother. The time of human birth is defined as the time at which the fetus comes out of the mother's womb into the world...
, birth complicated by infection of the placenta (chorioamnionitis
Chorioamnionitis
Chorioamnionitis is an inflammation of the fetal membranes due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labour...
), or have had umbilical catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
s.
Clinically, neonates with omphalitis present within the first two weeks of life with signs and symptoms of infection (cellulitis
Cellulitis
Cellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters,...
) around the umbilical stump (redness, warmth, swelling, pain), pus
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...
from the umbilical stump, fever
Fever
Fever is a common medical sign characterized by an elevation of temperature above the normal range of due to an increase in the body temperature regulatory set-point. This increase in set-point triggers increased muscle tone and shivering.As a person's temperature increases, there is, in...
, fast heart rate (tachycardia
Tachycardia
Tachycardia comes from the Greek words tachys and kardia . Tachycardia typically refers to a heart rate that exceeds the normal range for a resting heart rate...
), low blood pressure (hypotension
Hypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
), somnolence, poor feeding, and yellow skin (jaundice
Jaundice
Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae , and other mucous membranes caused by hyperbilirubinemia . This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid...
). Omphalitis can quickly progress to sepsis
Sepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
and presents a potentially life-threatening infection. In fact, even in cases of omphalitis without evidence of more serious infection such as necrotizing fasciitis
Necrotizing fasciitis
Necrotizing fasciitis , commonly known as flesh-eating disease or Flesh-eating bacteria syndrome, is a rare infection of the deeper layers of skin and subcutaneous tissues, easily spreading across the fascial plane within the subcutaneous tissue.Necrotizing fasciitis is a quickly progressing and...
, mortality is high (in the 10% range).
Microbiology of omphalitis
Omphalitis is most commonly caused by bacteria. The most common bacteria are Staphylococcus aureusStaphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
and Streptococcus
Streptococcus
Streptococcus is a genus of spherical Gram-positive bacteria belonging to the phylum Firmicutes and the lactic acid bacteria group. Cellular division occurs along a single axis in these bacteria, and thus they grow in chains or pairs, hence the name — from Greek στρεπτος streptos, meaning...
, Escherichia coli
Escherichia coli
Escherichia coli is a Gram-negative, rod-shaped bacterium that is commonly found in the lower intestine of warm-blooded organisms . Most E. coli strains are harmless, but some serotypes can cause serious food poisoning in humans, and are occasionally responsible for product recalls...
, and Klebsiella pneumoniae
Klebsiella pneumoniae
Klebsiella pneumoniae is a Gram-negative, non-motile, encapsulated, lactose fermenting, facultative anaerobic, rod shaped bacterium found in the normal flora of the mouth, skin, and intestines....
. The infection is typically caused by a mix of these organisms and is a mixed Gram-positive
Gram-positive
Gram-positive bacteria are those that are stained dark blue or violet by Gram staining. This is in contrast to Gram-negative bacteria, which cannot retain the crystal violet stain, instead taking up the counterstain and appearing red or pink...
and Gram-negative
Gram-negative
Gram-negative bacteria are bacteria that do not retain crystal violet dye in the Gram staining protocol. In a Gram stain test, a counterstain is added after the crystal violet, coloring all Gram-negative bacteria with a red or pink color...
infection. Anaerobic
Anaerobic organism
An anaerobic organism or anaerobe is any organism that does not require oxygen for growth. It could possibly react negatively and may even die if oxygen is present...
bacteria can also be involved.
Diagnosis
Diagnosis is usually made by the clinical appearance of the umbilical cord stump and the findings on history and physical examinationPhysical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
. There may be some confusion, however, if a well-appearing neonate simply has some redness around the umbilical stump. In fact, a mild degree is common, as is some bleeding at the stump site with detachment of the umbilical cord. The picture may be clouded even further if caustic agents have been used to clean the stump or if silver nitrate
Silver nitrate
Silver nitrate is an inorganic compound with chemical formula . This compound is a versatile precursor to many other silver compounds, such as those used in photography. It is far less sensitive to light than the halides...
has been used to cauterize
Cauterization
The medical practice or technique of cauterization is the burning of part of a body to remove or close off a part of it in a process called cautery, which destroys some tissue, in an attempt to mitigate damage, remove an undesired growth, or minimize other potential medical harmful possibilities...
granuloma
Granuloma
Granuloma is a medical term for a tiny collection of immune cells known as macrophages. Granulomas form when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate. Such substances include infectious organisms such as bacteria and fungi as well as...
ta of the umbilical stump.
Leukocyte Adhesion Deficiency is a rare (autosomal recessive disease) in which there is an absence of CD18.
Treatment
Treatment consists of antibioticAntibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
therapy aimed at the typical bacterial pathogen
Pathogen
A pathogen gignomai "I give birth to") or infectious agent — colloquially, a germ — is a microbe or microorganism such as a virus, bacterium, prion, or fungus that causes disease in its animal or plant host...
s in addition to supportive care for any complications which might result from the infection itself such as hypotension
Hypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
or respiratory failure
Respiratory failure
The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial...
. A typical regimen will include intravenous antibiotics such as from the penicillin-group
Penicillin
Penicillin is a group of antibiotics derived from Penicillium fungi. They include penicillin G, procaine penicillin, benzathine penicillin, and penicillin V....
which is active against Staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
and an aminoglycoside
Aminoglycoside
An aminoglycoside is a molecule or a portion of a molecule composed of amino-modifiedsugars.Several aminoglycosides function as antibiotics that are effective against certain types of bacteria...
for activity against gram-negative bacteria. For particularly invasive infections, antibiotics to cover anaerobic bacteria may be added (such as metronidazole
Metronidazole
Metronidazole is a nitroimidazole antibiotic medication used particularly for anaerobic bacteria and protozoa. Metronidazole is an antibiotic, amebicide, and antiprotozoal....
). Treatment is typically for two weeks and often necessitates insertion of a central venous catheter
Central venous catheter
In medicine, a central venous catheter is a catheter placed into a large vein in the neck , chest or groin...
or peripherally inserted central catheter
Peripherally inserted central catheter
A peripherally inserted central catheter is a form of intravenous access that can be used for a prolonged period of time...
.
Prevention
Each hospitalHospital
A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....
/birthing center
Birthing center
A birthing center or centre is a healthcare facility, staffed by nurse-midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. By attending the laboring mother, the doulas can assist the midwives and make the birth easier. The midwives monitor the...
has its own recommendations for care of the umbilical cord
Umbilical cord
In placental mammals, the umbilical cord is the connecting cord from the developing embryo or fetus to the placenta...
after delivery. Some recommend not using any medicinal washes on the cord. Other popular recommendations include triple dye, betadine
Betadine
Povidone-iodine is a stable chemical complex of polyvinylpyrrolidone and elemental iodine. It contains from 9.0% to 12.0% available iodine, calculated on a dry basis....
, bacitracin
Bacitracin
Bacitracin is a mixture of related cyclic polypeptides produced by organisms of the licheniformis group of Bacillus subtilis var Tracy, isolation of which was first reported in 1945....
, or silver sulfadiazine. There is little data to support any one treatment (or lack thereof) over another.