Omphalitis of the umbilicus: catarrhal, purulent, phlegmonous, necrotic

Omphalitis is an inflammatory process of the umbilical cord area and surrounding tissues, which is more common in newborns. The structure of the skin and subcutaneous tissue in infants is such that the inflammatory process spreads very quickly. Therefore, the risk of complications with omphalitis is very high, which proves the need to know the first symptoms and manifestations of this pathology.

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Epidemiology

Statistics show that today there are 2 to 7 cases of omphalitis per 100 newborns. This is a very high prevalence, considering the consequences. The average age of onset of symptoms depends on the gestational age: 3-5 days for premature babies; 5-9 days for full-term newborns. The frequency of complications depends on the start of treatment, and the later the treatment is started, the more the risk of death increases, and it can be in hours, not days.

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Causes omphalitis

The umbilical cord serves a vital function when the baby is in the womb. The umbilical cord contains two arteries and a vein, which are the main vessels that provide the baby with oxygen and remove carbon dioxide. After birth, the lungs take over this function, so the umbilical cord is tied and obliterated. The umbilical cord consists of two arteries and one vein, enclosed in mucous connective tissue and a thin mucous membrane. Usually after birth, inflammation at the proximal end of the umbilical cord leads to detachment of the umbilical cord from the skin. This natural process is accompanied by a whitish mucous discharge, which may be present under normal conditions.

It is important to understand that the navel is a direct gateway to the abdominal cavity, so any tissue infection can lead to rapid spread of the infection deep inside. After birth, a clamp is placed on the navel, and over time it falls off, leaving a dry and clean navel. Under normal conditions, the navel falls off between the fifth and fifteenth day after the birth of the child. After this period, the navel site should be dry, clean and should not bleed.

The umbilical cord is a suitable "culture medium" for bacterial growth and proliferation, as it contains living tissue that can easily become infected. Thus, the causes of omphalitis are microorganisms that enter the skin of the umbilicus and deeper tissues and cause an inflammatory process. The infection can spread to the umbilical blood vessels, the lymphatic vessels of the abdominal wall, and the blood vessels of the surrounding tissues.

Several bacterial species have been identified as the most common causative agents of this inflammation. A single species or a combination of both aerobic and anaerobic microbial species may cause omphalitis.

Aerobic organisms include: Staphylococcus aureus (most common), group A streptococcus, E. coli, Klebsiella, Proteus.

Anaerobic species cause approximately 30% of cases of omphalitis: Bacteroides fragilis, Peptostreptococcus, Clostridium perfringens.

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Pathogenesis

The pathogenesis of changes in omphalitis is that bacteria attract polymorphonuclear leukocytes to the umbilical cord as a natural defense mechanism of the body. The sources of potentially pathogenic bacteria that colonize the umbilical cord are the mother's birth canal and various local bacterial sources at the birth site. When leukocytes are the first to respond to the source of infection, monocytes and lymphocytes are then activated, which complement the inflammatory response. Various cytokines and biologically active substances are released, which lead to infiltration of the skin and soft tissues around the navel. This is how local inflammatory changes occur. The process very quickly spreads not only to deep tissues, but also to the subcutaneous tissue, which further supports the process of destruction of these tissues. Neutrophil infiltration occurs, which is characterized by pronounced exudative manifestations and the formation of a purulent process. If the child is not treated, foci of necrosis are formed, and the microorganism can penetrate the blood and cause sepsis.

There is such a thing as "omphalitis from a washcloth." What is it? When microorganisms get on the tissues of the umbilicus while it is healing, it causes inflammation. This concept implies that for some babies, the source of omphalitis may be improper care of the umbilicus at home or improper hygiene measures. This includes rubbing the unhealed umbilicus with a washcloth, treating the umbilical stump with antiseptic solutions, maceration of the umbilicus with a diaper, and other factors that lead to exogenous infection of the wound surface of the unhealed umbilicus. Therefore, the main factor in the development of omphalitis is improper postnatal care of the umbilicus. The method of umbilical cord care after birth affects both bacterial colonization and the time of separation of the umbilicus. Common risk factors for the development of neonatal omphalitis include unplanned home birth, low birth weight, prolonged rupture of membranes, umbilical catheterization, and chorioamnionitis. Risk factors also include immunodeficiency conditions in newborns; genetic defects associated with contractile proteins during labor; leukocyte adhesion deficiency syndrome and neutrophil motility defect. If the mother has chronic or acute inflammatory diseases of the genitals, these microorganisms colonize the baby's skin and may subsequently be the etiologic factor of omphalitis.

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Symptoms omphalitis

Symptoms of omphalitis can develop acutely in full-term babies, while in premature babies, the first signs may be latent due to an underdeveloped temperature reaction.

The clinical features of omphalitis vary in severity among children of different ages. The first signs of omphalitis in newborns are the emergence of feeding difficulties, and then the child becomes increasingly irritable, lethargic or sleepy, when the infection has already spread. Along with this, signs of a localized infection appear: the presence of an unpleasant smell of pus from the umbilical cord; redness of the skin around the navel, swelling of the skin in this area. Discharge from the navel may be transparent, but if they appear some time after the navel has begun to heal, then this should also be alarming. Temperature reaction in newborns does not often develop, but as intoxication increases against the background of the spread of infection deep into the tissues of the navel, the child's body temperature may also increase. Any change in the color of the skin around the navel can be considered one of the dangerous symptoms that can signal inflammation.

Acute omphalitis in older children is less common, since there is no direct gateway for infection. However, in children with immunodeficiencies, against the background of a wound infection or damage to the skin in this area, an inflammatory process of the navel may occur. Then the symptoms are more pronounced: intoxication; pain in the navel area, which the child points to; hyperthermia.

Omphalitis in adults is usually associated with inadequate hygiene and the deepening of the umbilical cord into the deep layers of subcutaneous tissue caused by obesity. Often, inflammation of the navel piercing is a consequence of the development of omphalitis in adults later. At first, there are characteristic skin changes that occur after damage to the umbilical cord or a week later. During this period, the wound in the navel is just beginning to heal, when discharge and an unpleasant odor appear. When necrotic tissue already appears around the umbilical ring, the skin becomes darker and may look like a strong blow or bruise. Ulcers may then appear and pain increases. Omphalitis in adults rarely leads to complications, since adults seek help at the initial stages. Omphalitis in newborns is considered more dangerous, since it is more difficult to diagnose, and the inflammatory process spreads lightning fast.

Depending on the degree of spread of the infectious process, there are some types of omphalitis. Simple omphalitis is characterized by initial manifestations without serious complications. This is usually the first day of the disease, when the process affects only the area of the skin around the navel. Catarrhal omphalitis develops when the skin and subcutaneous tissue are damaged at the onset of the disease. In this case, there may be initial manifestations of edema, redness of the skin and mucous discharge from the navel of a transparent nature. Serous omphalitis is the release of mucous contents of a serous nature from the navel, which can also occur under normal conditions. With a large microbial count in the inflammation focus, a huge number of neutrophilic leukocytes are mobilized, which is accompanied by their death and the release of pus. Thus, the catarrhal process can quickly turn into purulent omphalitis. This is accompanied by the appearance of an unpleasant odor from the inflamed tissues and green or yellow discharge.

If the process extends to deeper layers of skin and tissue, phlegmonous omphalitis develops. Phlegmonous omphalitis is caused by the production of factors (by one or more microorganisms) that directly lead to the death of tissue cells, the breakdown of cell membranes by bacterial enzymes. Toxins produced in the anaerobic environment of necrotic tissue allow organisms to spread quickly through tissue planes. This leads to the destruction of muscles and connective tissue, which allows organisms to continue to grow and increase toxin production. Due to the progressive deep destruction of tissue, such infections can be fatal if not treated quickly. In addition, the increase in local edema leads to compression of muscles within their fascia, which can lead to ischemic muscle necrosis and the development of necrotic omphalitis. This is the final stage of acute omphalitis, which in newborns is associated with a high risk of death.

Complications and consequences

Consequences and complications of omphalitis may occur when bacteria colonize the umbilical cord and directly access the bloodstream. The most common complications are the spread of infection involving healthy tissues. This is how necrotic fasciitis, abscess, phlegmon, and peritonitis develop.

Necrotizing fasciitis spreads quickly and can be fatal. The first signs may include swelling and redness of the skin around the infection, as well as tension of the skin and its sharp pain and crepitus when touched. Peritonitis develops when the vessels are involved in the process, because the umbilical vein is a direct route to the peritoneum. Thus, microorganisms from the skin enter the peritoneum and cause inflammation there.

Any complications of omphalitis greatly increase the risk of mortality.

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Diagnostics omphalitis

Diagnosis of omphalitis should be early, then the effect of treatment will be fast, and complications will develop with less probability. If there is any suspicious discharge from the navel or a change in skin color, then it is necessary to consult a doctor. Visual examination is important, since it is possible to determine the color of the skin, the nature of the discharge, its smell. It is necessary to clarify how the umbilical wound healed, if it is a newborn. In older children, it is necessary to clarify whether there was an injury to this area.

The tests that are necessary when omphalitis is suspected are a complete blood count. Changes in the form of neutrophilia or neutropenia indicate an acute infection. Sometimes, with progressive deterioration of the condition against the background of omphalitis, sepsis must be excluded. For this, broader indicators are studied - the ratio of the number of immature neutrophils to mature ones, which exceeds 0.2 in case of a systemic bacterial infection, and thrombocytopenia may also occur.

Other non-specific laboratory tests that can be used to assess the severity of the inflammatory process in omphalitis include: neutrophil CD64, procalcitonin, C-reactive protein, and erythrocyte sedimentation rate.

Confirmatory diagnostic criteria for sepsis and disseminated intravascular coagulation syndrome are: peripheral blood smear, fibrinogen, D-dimer, prothrombin time, and activated partial thromboplastin time. To isolate and identify microorganisms in omphalitis, smears from umbilical discharge and blood culture are used.

Instrumental diagnostics include: abdominal ultrasound diagnostics to detect the presence of peritonitis. Ultrasonography and CT show anatomical abnormalities, fascial thickening and fluid in the tissues.

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Differential diagnosis

Differential diagnostics of omphalitis should be carried out primarily with a normal serous process, which can occur with normal healing of the navel. Under normal conditions, there may be fluid accumulation in the navel area between the umbilical cord and the abdominal wall. This may manifest itself as serous discharge after the navel falls off. But if there is no redness of systemic reactions, then this is not omphalitis.

Delayed epithelialization of the umbilicus may leave a dull gray-pink granuloma that oozes fluid. Such a granuloma must be differentiated from an abscess.

It is also necessary to differentiate omphalitis and umbilical fistula. Umbilical fistula can occur when infection from the abdominal cavity through a pliable place - the navel - begins to get on the skin. In this case, the umbilical opening itself is not involved in the inflammation process. With omphalitis, inflammation of the soft tissues around the navel primarily occurs, which can be seen immediately.

Treatment omphalitis

Treatment of omphalitis is always carried out in hospital. If the child is premature or newborn, it may be necessary to treat him in intensive care.

The goal of omphalitis treatment is to eliminate bacterial pathogens and correct associated symptoms with the prevention of complications. Prompt and adequate use of antimicrobial drugs is essential. Antibiotics are mandatory for omphalitis; sometimes it is necessary to use even two drugs simultaneously. The results of susceptibility tests should determine the choice of antibiotics. A combination of ampiox, oxacillin, methicillin and gentamicin with metronidazole for anaerobes is recommended. Short-term treatment for 7 days is suitable in uncomplicated cases, and in more complex cases with the development of complications, 10-14 days of parenteral administration are necessary. In case of complications such as hypotension, disseminated intravascular coagulation and respiratory failure, it is recommended to administer intravascular fluids and transfused blood or plasma.

Empirical antimicrobial therapy should be comprehensive and should cover all possible pathogens in the context of the clinical situation. Drugs that may be used include:

1. Ampicillin is a broad-spectrum penicillin. It prevents bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. It is bactericidal against organisms such as Listeria, some staphylococci, some strains of Haemophilus influenzae, and meningococci. The dosage for intramuscular and intravenous administration is 45 milligrams per kilogram. The drug should be divided into three doses. Side effects include liver dysfunction and diarrhea. Precautions: Do not use if there is a family history of penicillin allergy.
2. Oxacillin is an antistaphylococcal penicillin that acts specifically on this pathogen. A bactericidal antibiotic that inhibits cell wall synthesis. It is used to treat infections caused by penicillinase-producing staphylococci. It can be used to initiate therapy if a staphylococcal infection is suspected. Dosage is 50 milligrams per kilogram. Side effects include visual impairment, allergic rash, and intestinal dysfunction.
3. Netilmicin is an aminoglycoside antibiotic that acts against gram-negative bacteria. The dosage of the drug for intravenous administration is 10 milligrams per kilogram of body weight. In the acute period, the antibiotic is administered intravenously. Side effects may include toxic effects on the hearing organs, kidneys, and allergic reactions.
4. Clindamycin – used to treat infections caused by anaerobic bacteria. The drug is also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth by blocking the dissociation of peptidyl-tRNA from ribosomes, which leads to the cessation of RNA-dependent protein synthesis. Dosage – 8-10 milligrams per kilogram. Side effects – allergic reactions, effects on the organ of vision.
5. Vancomycin is an antibiotic that is a bactericidal agent against most aerobic and anaerobic gram-positive cocci and bacilli. It is a reserve drug and is recommended in therapy for suspected coagulase-negative staphylococcal sepsis. Dosage - initial dose of 15 milligrams, then 10 milligrams per kilogram of body weight. Side effects - respiratory distress, neutropenia.

Thus, antibiotics are mandatory drugs in the treatment of omphalitis. In addition, symptomatic therapy is used - antipyretics, infusion therapy to relieve intoxication. Ointments for omphalitis are rarely used, since with a pronounced inflammatory process they can lead to a violation of the healing process. Levomekol is an ointment that is often used for simple omphalitis. This is a hydrophilic ointment that has the property of drawing out purulent and mucous contents. It is used in the acute period as prescribed by a doctor.

Vitamins and physiotherapy can be used once the child has recovered.

Traditional and herbal treatments are limited, since omphalitis is an inflammatory process that spreads very quickly and leads to consequences, so such methods can only complicate its course.

Morbidity and mortality in omphalitis depend on the development of complications and the start of timely treatment. Therefore, medical intervention in omphalitis should be based on the complex treatment of surgical complications. Surgical treatment is carried out when purulent contents appear in the navel area - primary surgical treatment. If there are other complications, then antibacterial therapy must be supplemented by surgical intervention. Surgery for omphalitis is carried out to sanitize the source of infection and drainage.

Necrotizing fasciitis is characterized by the formation of areas of necrosis of the fascia and then the muscles. The main task of treating this complication is the removal of dead or degenerated tissue by wound treatment and irrigation. After healing, large wounds can later be sutured or replaced with a skin graft.

Peritonitis without abdominal abscess may not require surgical intervention, and the infection can be controlled with broad-spectrum intravenous antibiotics. An intraperitoneal abscess confirmed by ultrasonography or laparotomy should be completely debrided surgically and drained. An intraperitoneal abscess should be debrided at laparotomy.

Prevention

Prevention of omphalitis is, first of all, proper care of the umbilical cord of the newborn. Today, this concept includes as little intervention as possible from the staff and parents, as well as the need for a dry and clean navel at all times. Therefore, after discharge home, there is no need to lubricate the navel with anything, but simply bathe the child in clean boiled water, without rubbing the healing site of the navel. Prevention of complications is important, therefore, if any discharge from the navel appears or the general condition of the child deteriorates against this background, it is necessary to consult a doctor.

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Forecast

The prognosis for omphalitis is generally favorable, but complications, if not treated in time, can lead to mortality of up to 7-15%. In 4% of newborns with a localized form of omphalitis, a clinical picture of sepsis develops. Mortality, despite the successes of modern medicine, remains high, reaching 30-40% in full-term children, 50% or more in premature babies. Such a prognosis once again proves the high need for timely diagnosis of omphalitis.

Omphalitis is a pathology that can be seen, therefore, despite the rapid spread of inflammation in omphalitis, its diagnosis should be made even by mothers based on a visual assessment of the navel. Untimely diagnosis and treatment of omphalitis leads to disability or death of children. Therefore, prevention, timely diagnosis, effective treatment have not only medical but also social significance.