OMPHALITIS MEDICATION COMPLICATIONS
Category: Child Health
Abstract : MEDICATION A combination of a parenterally administered antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended for uncomplicated omphalitis. Some believe that anaerobic coverage also should be considered in all infants with omphalitis. Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, and antimicrobial therapy directed at
MEDICATION
A combination of a parenterally administered antistaphylococcal penicillin and an aminoglycoside antibiotic is recommended for uncomplicated omphalitis. Some believe that anaerobic coverage also should be considered in all infants with omphalitis.
Omphalitis complicated by necrotizing fasciitis or myonecrosis requires a more aggressive approach, and antimicrobial therapy directed at anaerobic organisms, as well as gram-positive and gram-negative organisms, is suggested. Metronidazole may be added to the combination of antistaphylococcal penicillin and aminoglycoside to provide anaerobic biopsy specimen culturing. Blood products (eg, packed red blood cells, platelets, fresh frozen plasma) and other medications (eg, inotropic agents, sodium bicarbonate) may be required for supportive care.
Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
FOLLOW-UP
Further Inpatient Care:
• Examine the patient frequently, and immediately debride any tissue showing signs of advancing infection or necrosis. Postoperatively, inspect the gross appearance of the tissue on the perimeter of the debrided area several times a day or more frequently if the infant has any unresolved signs of systemic infection.
• Monitor aminoglycoside levels, and adjust dose accordingly.
• Monitor and manage metabolic abnormalities, which are common in any ill neonate.
Further Outpatient Care:
• Routine postsurgical follow-up care is indicated.
• Infants developing portal vein thrombosis require follow-up care for complications associated with portal hypertension.
In/Out Patient Meds:
IV antimicrobial therapy with an antistaphylococcal penicillin, aminoglycoside, and clindamycin, or metronidazole if indicated, are administered during hospitalization.
Transfer:
Critically ill infants, including those who may require surgical intervention, may require transfer to an ICU equipped to treat infants. Transport the patient with advanced life support technology in place and qualified personnel in attendance. Options for further treatment or intervention must be immediately available.
Deterrence/Prevention:
• Antimicrobial agents are applied to the umbilicus to decrease bacterial colonization and to prevent omphalitis and associated complications. Several effective umbilical cord care regimens are available, including the following:
o Triple dye applied once daily until cord separation
o Triple dye applied once, then alcohol applied daily until cord separation
o Triple dye applied once, then no further antimicrobial treatment
o Povidone-iodine applied daily until cord separation
o Silver sulfadiazine applied daily until cord separation
o Bacitracin ointment applied daily until cord separation
o Gladstone and colleagues evaluated these regimens and found no significant difference in either the incidence or type of bacteria colonizing the umbilical stump among 271 healthy full-term infants. However, the duration of umbilical cord attachment was significantly less in infants treated with either povidone-iodine daily (9.8 d), bacitracin daily (11.8 d), triple dye applied once followed by alcohol daily (12.5 d), silver sulfadiazine daily (13.8 d), or triple dye once (12.9), compared to infants in whom triple dye was applied daily (17.4 d). No infant developed omphalitis in this study of full-term newborns with uncomplicated births not requiring instruments.
Complications:
• The sequelae of omphalitis may be associated with significant morbidity and mortality. These include necrotizing fasciitis, myonecrosis, endocarditis, portal vein thrombosis, sepsis, septic embolization, and death.
o Necrotizing fasciitis is a florid bacterial infection of the skin, subcutaneous fat, and superficial and deep fascia that complicates 8-16% of cases of neonatal omphalitis. It is characterized by rapidly spreading infection and severe systemic toxicity.
- Necrotizing soft tissue infections are caused by production of factors (by single or multiple organisms) that lead directly to tissue cell death, enzymatic destruction of supporting connective tissue, and destruction of host humoral and cellular immune responses to infecting organisms.
- Certain organisms are well known to invade tissue and proliferate in necrotic areas. Group A Streptococcus, S aureus, and Clostridium species may elaborate extracellular enzymes and toxins that can damage tissue, may facilitate movement of organisms through soft tissue planes, and may limit host defenses and penetration of systemic antimicrobial agents.
o Myonecrosis refers to infectious involvement of muscle.
- In infants with omphalitis, development of myonecrosis usually depends on conditions that facilitate the growth of anaerobic organisms. These conditions include the presence of necrotic tissue, poor blood supply, foreign material, and established infection by aerobic bacteria such as staphylococci or streptococci. C perfringens, in particular, does not replicate under conditions of an oxidation-reduction potential (Eh) greater than -80 mV; the Eh of healthy muscle is 120-160 mV. In infections with mixtures of facultative aerobes and anaerobes, the aerobic organisms use oxygen available in tissue, thereby further reducing the Eh in tissues inoculated by Clostridium species or other anaerobic bacteria, often to less than -150 mV, allowing anaerobic bacterial growth.
- The toxins produced in the anaerobic environment of necrotic tissue allow rapid spread of organisms through tissue planes. Local spread of toxins extends the area of tissue necrosis, allowing continued growth of organisms and increasing elaboration of toxins. Because of progressive deep tissue destruction and subsequent systemic spread of toxins, anaerobic infections, in particular, may be fatal if not treated promptly. In addition, rapid development of edema, which constricts the muscle within its fascia, may lead to ischemic myonecrosis.
o Septic embolization: If septic embolization arises from infected umbilical vessels, it may lead to metastatic foci in various organs, including the liver, lungs, pancreas, kidneys, and skin.
o Sepsis: This is the most common complication of omphalitis. In a study by Mason and colleagues, bacteremia was a complication in 13% of infants with omphalitis. In these infants, DIC and multiple organ failure may occur.
o Other complications related to omphalitis are much less common.
Prognosis: The prognosis for infants with omphalitis is variable.
Patient Education: Referral for psychosocial counseling may assist the family in coping with a critically ill infant.
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