OMPHALITIS

1. OMPHALITIS By Dr Olubunmi A. Lawal

2. Omphalitis Introduction Epidemiology / Frequency Aetiology Pathophysiology Clinical Features Management History Physical Examination Investigation Treatment Prevention Complications Prognosis Differential Diagnosis

3. Introduction Omphalitis is an infection of the umbilical stump. It typically present as a superficial cellulitis i.e. as a red ‘flare’ in the periumbilical skin. The cellulitis may progress rapidly with potentially serious consequences including systemic disease e.t.c. Omphalitis is predominantly a disease of the Neonates.

4. Epidemiology / Frequency Internationally, overall incidence is < 1% Incidence varies from 0.2% to 0.7% in developed countries. Omphalitis has become rare in industrialized countries. It still remains a common cause of Neonatal mortality in the less developed countries. Incidence is higher in hospitalized preterm infants than full term infants. Episodes of Omphalitis are reported and usually are sporadic. Rarely, epidemics can occur due to group A Streptococcus. No sex predilection has been reported, although males have a worse prognosis than females. Introduction of aseptic cord care has greatly reduced the occurrence.

5. Aetiology Approximately 85% OF Cases are polymicrobial in origin. Aerobic bacteria present in 85% of infections predominated by Staphylococcus aureus, Group A Streptococcus, Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. Recent studies have high lightened gram negative organisms as the cause. Change in aetiology may be caused by prophylactic umbilical cord care using anti Staphlococcal agents. A 3rd of the patients have infection caused by Anaerobes, predominantly Bacteriodes fragilis and Clostridium perfringes. Pseudomonas species have been implicated in particularly rapid or invasive disease.

6. Pathophysiology The umbilical cord represent a unique but universally acquired wound in which devitalized tissues provides a medium that support bacterial growth. Normally the cord area is colonized with potential bacterial pathogen during or soon after birth. These bacteria have the potential to invade the umbilical stump, leading to Omphalitis. THE FACTORS THAT CAUSE COLONIZATION TO PROGRESS TO INFECTION ARE NOT WELL UNDERSTOOD.

7. Some proposed factors It is a polymicrobial infections cause by a mixture of aerobic and anaerobic organisms. Associated risk factors include; LBW Prior umbilical catheterization Septic delivery (premature rupture of membrane, non sterile delivery, or maternal infection, Prolonged rupture of membrane)

8. Omphalitis occasionally manifests from an underlying Immunologic disorder. These infants are subsequently diagnosed with Leukocyte adhesion deficiency, a rare disorder with AR pattern of inheritance. These infants present with the fllg; Leukocytosis, Delayed seperation of the umbilical cord and recurrent infections. Omphalitis may also be the initial manifestation of Neutropenia in neonates i.e. NN Alloimune Neutropenia. Affected infants present with cutaneous infections, sepsis, pneumonia e.t.c. Rarely, an anatomic abnormality may be present such as a patent urachus or patent ompalomesenteric duct.

9. Clinical Features In term infant the, mean age at onset is 5-9 days. In preterm infants, the mean age at onset is 3-5 days. Patient present with redness and swelling (cellulitis) around the umbilicus. Purulent or mal odorous discharge from the umbilicus. Baby is highly irritable. The cellulitis is rapidly progressive and may lead to necrotizing fasciitis. Necrotizing fasciitis is characterized by abdominal distension, fever and tachycardia. Despite the illness, most of the neonates at presentation have good appetite and continue to suck.

10. Management History- detailed history of the pregnancy, labour, delivery and neonatal course. Physical Examination Physical signs vary with the extent of the disease. Local disease; signs of localized infection include the fllg Purulent or mal odorous discharge from the umbilical stump Periumbilical erythema Edema Tenderness Extensive local disease; such as fasciitis or myonecrosis. These signs may suggest infection by both aerobic or anaerobic organisms. Periumbilical ecchymosis Crepitus Bullae Progression of cellulitis despite antimicrobial therapy

11. Systemic disease; non specific and include disturbances of thermoregulation or evidence of dysfunction of multiple organ systems e.g. Disturbance of thermoregulation; fever T>38ºC, hypothermia T < 36ºC or temp instability. CVS disturbances: PR> 180bpm, hypotension (SBP <60mmHg in term infants) or delayed capillary refill (<2-3secs) Respiratory disturbances- Apnea, tachypnea (RR>60cpm), grunting, flaring alae nasi, intercoastal or sub coastal retractions or hypoxemia GIT disturbance- rigid or distended abd or absent bowel sounds. Cutaneous abnormalities-jaundice,petechiae or cyanosis Neurologic abnormalities- irritability, lethargy, weak sucking, hypotonia or hypertonia.

12. Baby O.T.with extensive local disease & systemic disease

13. Investigation The clinical picture of Omphalitis is sufficiently characteristic that diagnosis can be made with fair certainty on clinical grounds. Determining whether associated complications are present, such as systemic infection, necrotizing fasciitis, myonecrosis, or portal vein thrombosis is important.

14. Lab studies Obtain specimen from umbilical infection for Gram stain & culture for aerobic and anaerobic organisms. Blood culture for aerobic and anaerobic organisms. PCV, WBC, Platelets, film appearance. Neutrophilia or Neutropenia may be present in acute infection. Thrombocytopenia may be present. RBS –hypoglycaemia E&U- metabolic acidosis Other non specific lab tests. None has demonstrated sensitivity or specificity sufficiently high to dictate clinical care. These are; C-reactive protein level Erythrocyte Sedimentation rate Limulus lysate test, which detect endotoxin

15. Imaging studies Abdominal radiographs may reveal Intra abdominal wall gas. Computed tomographic (CT) scan of the abdomen may determine the presence & extent of muscle involvement.

16. Procedures LP may be warranted in infants in whom sepsis is suspected. Anterior abdominal wall Biopsy: Histologic findings may reveal Necrotizing fasciitis, which is an acute inflammatory infiltrate found in subcutaneous fat and connective tissue, or Myonecrosis, which is an acute inflammatory process surrounding muscle bundles many of which are no longer viable.

17. Treatment

18. Antimicrobial therapy Parenteral antimicrobial coverage for gram - positive and gram – negative organisms. A combination of anti – Staphylococcal penicillin and an Aminoglycoside is recommended. Anaerobic coverage is important in all patients. As with anti microbial therapy, local antibiotic sensitivity patterns is considered. In our Centre, CLOXACILLIN + GENTAMICIN + FLAGYL OR CEPHALOSPORIN + GENTAMICIN +FLAGYL forms the usual antimicrobial combination.

19. In most of our patients organisms cultured are sensitive to virtually all matched antibiotics. Expect erythema of the umbilical stump to improve with 12 -24hrs after the initiation of a antimicrobial therapy – NOT USUALLY THE CASE HERE.

20. Steroid It is used for Its anti inflammatory effect. Its effect on immunologic reactions. DEXAMATHASONE intravenously at a dose of 0.5mg / kg / dose 6 hourly is used in this centre.

21. Supportive care It is essential to survival. These measures include; Administer fluid for hypotension. Blood products – Packed red blood cells, platelets, fresh frozen plasma, or cryoprecipitate for DIC may be required. Plasma transfusion in this centre has helped to prolong life by a few hours. Monitor & manage metabolic abnormalities which are common in any ill neonate. Diet; parenteral nutrition is required in infants with Omphalitis, enteral feeding may be resumed once acute infection resolves. Monitor patients for progression of the disease. Provide ventilatory assistance and supplemental 0xygen for hypoxaemia or apnea.

22. Surgical care Early surgery may be life saving. It involves early and complete surgical debridement of the affected tissues and muscle. Excision of pre peritoneal tissue ( umbilicus, umbilical vessels & urachal remnant ) is critically important in the eradication of infection. These tissues can harbour invasive bacteria and provide a route for progressive spread of infection. Most of our patients die in the acute phase usually the 3rd to 4th day of presentation. The surgical method has not been tried out here.

23. Prevention Good Ante natal care. Supervised aseptic delivery. Cord care with antimicrobial agents to decrease bacterial colonization. E.g. Methylated spirit (an alcohol) applied several times a day until cord seperation. Others agents are povidone iodine, silver sulfadiazine & bacitracin ointment. Discourage harmful practices e.g. application of cow dung & hot water formentation to the cord.

24. Complications The sequelae of Omphalitis is associated with significant morbidity and mortality. Necrotizing fasciitis Myonecrosis Septic embolization from infected umbilical vessel. Septicaemia. DIC and multiple organ failure may occur. Portal vein thrombosis = portal hypertension. Death.

25. Prognosis The prognosis for most infants is variable. In most cases prognosis is Poor. Omphalitis with complications is associated with mortality rate up to 80% in developed countries. In the less developed countries, mortality is > 95%

26. Differential diagnosis Anterior abdominal wall cellulitis Neonatal septicaemia Burns Urachal cyst with 2º bacterial infection.

27. THE END THANK YOU .