OMPHALITIS MEDICAL SURGICAL CARE

Medical Care:
Treatment of omphalitis (periumbilical edema, erythema, and tenderness) in the newborn includes antimicrobial therapy and supportive care.

• Antimicrobial therapy
o Include parenteral antimicrobial coverage for gram-positive and gram-negative organisms. A combination of an antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended.

o Some believe that anaerobic coverage is important in all patients. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, with antimicrobial therapy directed at anaerobic organisms as well as gram-positive and gram-negative organisms.
- Metronidazole may provide anaerobic coverage.
- Clindamycin may be substituted for the antistaphylococcal penicillin.
- As with antimicrobial therapy for other infections, consider local antibiotic susceptibility patterns.
- Pseudomonas species have been implicated in particularly rapid or invasive disease.

o Expect erythema of the umbilical stump to improve within 12-24 hours after the initiation of antimicrobial therapy.

• Supportive care:
In addition to antimicrobial therapy, supportive care is essential to survival. These measures include the following:
o Provide ventilatory assistance and supplementary oxygen for hypoxemia or apnea unresponsive to stimulation.
o Administer fluid, vasoactive agents, or both for hypotension.
o Administration of platelets, fresh frozen plasma, or cryoprecipitate for DIC and clinical bleeding is suggested.
o Treat infants at centers capable of supporting cardiopulmonary function.

• Other treatment considerations
o Monitor patients for progression of disease. Early surgical intervention may be lifesaving.
o The role of hyperbaric oxygen in treatment of patients with anaerobic necrotizing fasciitis and myonecrosis is controversial because no prospective controlled data are available and pediatric data are scarce. In the treatment chambers, tissue levels of oxygen are maximized when the patient breathes 100% oxygen at 2-3 atm. The delivery of high concentrations of oxygen to marginally perfused tissues may have a detrimental effect on the growth of anaerobic organisms and improve phagocyte function. However, surgical therapy has the highest priority, and initiation of hyperbaric oxygen therapy should not delay transport to a facility with staff capable of performing surgical debridement.

Surgical Care:
• Management of necrotizing fasciitis and myonecrosis involves early and complete surgical debridement of the affected tissue and muscle. Although the extent of debridement depends on the viability of tissue and muscle, which is determined at the time of surgery, excision of preperitoneal tissue (including the umbilicus, umbilical vessels, and urachal remnant) is critically important in the eradication of the infection. These tissues can harbor invasive bacteria and provide a route for progressive spread of infection after less extensive debridement. Delay in diagnosis or surgery allows progression and spread of necrosis, leading to extensive tissue loss and worsening systemic toxicity. Several surgical procedures may be required before all nonviable tissue is removed.

Consultations:
• Infectious disease specialist - For appropriate antimicrobial selection, particularly if necrotizing fasciitis or myonecrosis occurs
• Surgeon - If necrotizing fasciitis or myonecrosis is suspected (consult early in the disease course)

Diet:
• Once omphalitis is suspected, do not feed the infant enterally. Enteral feedings may be resumed once the acute infection resolves.
• Parenteral nutrition is required in infants with omphalitis.