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

Omphalitis is a process of inflammation of the umbilical cord and surrounding tissue, which is more common in newborns. Features of the structure of the skin and subcutaneous tissue in infants are such that the inflammatory process spreads very quickly. Therefore, the risk of complications in omphalitis is very large, which proves the need for knowledge of the first symptoms and manifestations of this pathology.

[1], [2], [3]

Epidemiology

Statistics show that to date, there are 2 to 7 cases of omphalitis per 100 newborns. This is a very high prevalence, given the consequences. The average age of symptoms depends on the gestation period: 3-5 days for premature infants; 5-9 days for full-term newborns. The frequency of complications depends on the beginning of the treatment, and the later the treatment begins, the greater the risk of a fatal outcome, and the bill may be for hours, not days.

[4], [5]

Causes of the omphalitis

The navel performs a vital function when the baby is in utero. The umbilical cord contains two arteries and a vein, which are the main vessels that provide the baby with oxygen delivery and carbon dioxide removal. After birth, this function is performed by the lungs, so the umbilical cord is bandaged and obliterated. The umbilical cord consists of two arteries and one vein, enclosed in a mucous connective tissue and a thin mucous membrane. Usually, after birth, inflammation at the proximal end of the cord leads to detachment of the umbilical cord from the skin. This natural process is accompanied by whitish mucus secretions, which under normal conditions can be.

It should be understood that the navel is the direct gateway to the abdominal cavity, so any infection of tissues can lead to a rapid spread of the infection deep into the stomach. After birth, a terminal is attached to the navel, and eventually it disappears and a dry and clean navel remains. Under normal conditions, the navel falls between the fifth and fifteenth days after the birth of the child. At the end of this period, the navel should be clean, dry and clean, and not bleed.

The umbilical cord is a suitable "culture medium" for bacterial growth and proliferation, because there are living tissues that can easily become infected. Thus, the causes of omphalitis are microorganisms that fall on the skin of the navel and deeper tissues and cause an inflammatory process. Infection can spread to umbilical blood vessels, lymphatic vessels of the abdominal wall and blood vessels of surrounding tissues.

Several species of bacteria have been identified as pathogens, which most often cause such inflammation. A separate species or a combination of both aerobic and anaerobic microbial species can cause omphalitis.

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

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

[6], [7], [8], [9]

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. Sources of potentially pathogenic bacteria that colonize the umbilical cord are the mother's maternal canal and various local bacterial sources at the birth site. When the white blood cells are the first to react to the source of infection, then monocytes and lymphocytes are activated, which supplements the inflammatory reaction. Various cytokines and biologically active substances that lead to infiltration of the skin and soft tissues around the navel are distinguished. So there are local inflammatory changes. The process very quickly extends not only to the deep tissue, but also to the subcutaneous tissue, which further supports the process of destruction of these tissues. There is infiltration with neutrophils, which is characterized by pronounced exudative manifestations and the formation of a purulent process. If the child is not treated, then foci of necrosis are formed, and the microorganism can enter the blood and cause sepsis.

There is such a thing as "omphalitis from a washcloth". What it is? The ingress of microorganisms onto the navel tissue, when it heals, leads to inflammation. This concept implies the fact that for some children the source of omphalitis may be improper care of the navel of the house or improper hygiene measures. This includes rubbing the unhealed navel with a washcloth, treating the umbilical remainder with antiseptic solutions, maculating the navel with a diaper, and other factors that lead to exogenous infection of the wound surface of the uninhabited navel. Therefore, the main factor in the development of omphalitis is incorrect postpartum care for the navel. The method of caring for the umbilical cord after birth affects both bacterial colonization and the time of separation of the navel. Common risk factors for developing neonatal omphalitis include unplanned home births, low birth weight, prolonged rupture of membranes, umbilical catheterization, and chorioamnionitis. Also, risk factors include immunodeficiency states in newborns; genetic defects associated with contractile proteins during labor; syndrome of deficit of adhesion of leukocytes and a defect of mobility of neutrophils. If the mother has inflammatory diseases of the genital organs of a chronic or acute nature, these microorganisms colonize the skin of the child and may be an etiological factor of omphalitis.

[10], [11],

Symptoms of the omphalitis

Symptoms of omphalitis can develop acute in term infants, whereas in preterm infants, the first signs can be erased due to an undeveloped temperature response.

Clinical features of omphalitis differ in severity among children of different ages. The first signs of omphalitis in newborns are the occurrence of difficulties with feeding, and then the child becomes more irritable, lethargic or sleepy when the infection is already spreading. Along with this, there are signs of localized infection: the presence of an unpleasant odor of pus from the umbilical cord; redness of the skin around the navel, swelling of the skin in this area. Excretions from the navel can be transparent, but if they appeared some time after the navel began to heal, then it should also alert. The temperature reaction in newborns does not develop often, but, as the intoxication grows against the background of the spread of infection deep into the tissues of the navel, the child's body temperature can also increase. Any change in skin color around the navel can be considered one of the dangerous symptoms that can signal an inflammation.

Acute omphalitis in older children is less common, since there are no direct gates for infection. But, nevertheless, in children with immunodeficiencies against the background of wound infection or skin lesions in this area, the inflammatory process of the navel may occur. Then the symptoms are more pronounced: intoxication; pain in the navel, pointed to by the child; hyperthermia.

Omphalitis in adults is usually associated with inadequate hygiene and deepening of the umbilical cord into deep spheres of subcutaneous tissue caused by obesity. Often inflammation of the navel piercing is a consequence of the development of omphalitis in adults in the future. First, there are characteristic skin changes that occur after the umbilical cord is damaged or a week after. During this period, the wound in the navel only begins to heal when there are discharge and an unpleasant odor. When necrotic tissue around the umbilical ring appears, the skin becomes darker and may look like a strong punch or bruise. Then ulcers can appear and painful sensations increase. Omphalitis in adults rarely leads to complications, because adults seek help at an early stage. Omphalitis in newborns is considered more dangerous, because it is more difficult to diagnose, and the process of inflammation spreads with lightning speed.

In terms of the spread of the infectious process, some types of omphalitis are distinguished. Simple omphalitis is characterized by initial manifestations without serious complications. This is usually the first day of the disease, when the process covers only the area of the skin around the navel. Catarrhal omphalitis develops when skin and subcutaneous tissue damage occurs at the onset of the disease. In this case, there may be initial manifestations of edema, reddening of the skin and mucous discharge from the navel of a transparent nature. Serous omphalitis is a secretion of mucous contents of a serous character from the navel, which can be in normal conditions. When a large number of microbes in the focus of inflammation, a huge amount of neutrophilic leukocytes is mobilized, which is accompanied by their death and the release of pus. So the catarrhal process can quickly pass into a purulent omphalitis. This is accompanied by the appearance of an unpleasant odor from inflamed tissues and green or yellow discharge.

If the process extends to the deeper layers of the skin and fiber, then phlegmonous omphalitis develops. Phlegmonous omphalitis is caused by the production of factors (one or several microorganisms), which directly lead to the death of tissue cells, enzymatic cleavage of the bacterium of cell membranes. Toxins produced in the anaerobic environment of necrotic tissue allow the rapid spread of organisms through tissue planes. This leads to the fact that the muscles and connective tissue is destroyed, which allows the continued growth of organisms and increase the production of toxins. Because of progressive deep destruction of tissues, such infections can be fatal if not treated quickly. In addition, the increase in local edema leads to compression of the muscles inside its fascia, which can lead to ischemic necrosis of the muscles 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

The consequences and complications of omphalitis can occur when bacteria are colonized by the umbilical cord and direct access to the blood flow. The most common complication is the spread of infection with the involvement of healthy tissues. This is how the necrotizing fasciitis, abscess, phlegmon, peritonitis develops.

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 skin tension and its sharp soreness and crepitus when touching. Peritonitis develops when the vessels are involved in the process, because the umbilical vein is the direct path to the peritoneum. Thus, microorganisms from the skin enter the peritoneum and cause inflammation there.

Any complications of omphalitis greatly increase the risk of death.

[12], [13], [14], [15], [16], [17]

Diagnostics of the omphalitis

Diagnosis of omphalitis should be early, then the effect of treatment will be rapid, and complications will develop with less probability. If there is any suspicious discharge from the navel or a discoloration of the skin, then it is necessary to consult a doctor. Visual inspection is important, because you can determine the skin color, the nature of the secretions, their smell. It is necessary to clarify how the healing of the umbilical wound occurred, if it is a newborn. In older children, it is necessary to clarify whether there was a trauma in this area.

Analyzes that are necessary for suspected omphalitis are a common blood test. Changes in the form of neutrophilia or neutropenia indicate an acute infection. Sometimes, with progressive deterioration of the condition against the background of omphalitis, it is necessary to exclude sepsis. To do this, study broader indicators - the ratio of the number of immature neutrophils to mature, which exceeds 0.2 for systemic bacterial infection, and may also be thrombocytopenia.

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

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

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

[18], [19], [20]

Differential diagnosis

Differential diagnosis of omphalitis should be conducted primarily with the usual serous process, which can be with normal healing of the navel. Under normal conditions, in the navel area, there may be fluid accumulation between the umbilical cord and the abdominal wall. This can be manifested by serous discharge after the navel falls off. But if there is no redness of systemic reactions, then this is not an omphalitis.

Delayed epithelialization of the navel can leave a dull gray-pink granuloma that seeps through the liquid. Such a granuloma should be differentiated with an abscess.

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

Treatment of the omphalitis

Treatment of omphalitis is mandatory in a hospital. If the baby is premature or newborn, there may be a need to treat it in intensive care.

The goal of omphalitis treatment is the elimination of bacterial pathogens and the correction of concomitant symptoms with the prevention of complications. Rapid and adequate use of antimicrobials is important. Antibiotics for omphalitis are mandatory, sometimes there is a need to use even two drugs at the same time. The results of sensitivity tests should determine the choice of antibiotics. It is recommended to combine ampiox, oxacillin, methicillin and gentamicin with metronidazole for anaerobes. 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 the case of complications such as hypotension, disseminated intravascular coagulation and respiratory insufficiency, 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. Medications that can be used are:

1. Ampicillin is a broad-spectrum penicillin. Prevents the synthesis of the bacterial cell wall during active replication, causing bactericidal activity against susceptible organisms. Bactericide for organisms such as Listeria, certain staphylococci, some strains of Haemophilus influenzae and meningococci. The dosage of the drug for intramuscular and intravenous administration is 45 milligrams per kilogram. The drug should be divided into three injections. Side effects - liver dysfunction, diarrhea. Precautions - do not use for allergies to penicillins in the family.
2. Oxacillin is an antistaphylococcal penicillin that acts specifically on this pathogen. A bactericidal antibiotic that inhibits the synthesis of the cell wall. Used in the treatment of infections caused by penicillinase-producing staphylococci. Can be used to initiate therapy for suspected staphylococcal infection. Dosage - 50 milligrams per kilogram. Side effects - visual impairment, allergic rash, intestinal dysfunction.
3. Nethylmicin 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 an acute period, the antibiotic is administered intravenously. Side effects can be in the form of toxic effects on the organs of hearing, kidneys, as well as allergic reactions.
4. Clindamycin - is used to treat infections caused by anaerobic bacteria. The drug is also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits the growth of bacteria by blocking the dissociation of peptidyl-tRNA from the ribosomes, which leads to the arrest of the synthesis of the RNA-dependent protein. Dosage is 8-10 milligrams per kilogram. Side effects are allergic reactions, action 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 is the initial dose of 15 milligrams, and then 10 milligrams per kilogram of body weight. Side effects - breathing disorders, neutropenia.

Thus, antibiotics in the treatment of omphalitis are mandatory drugs. In addition, symptomatic therapy is used - antipyretics, infusion therapy for the removal of intoxication. Ointments from omphalitis are rarely used, because with a pronounced inflammatory process they can lead to disruption of the healing process. Levomekol is an ointment that is often used in simple omphalitis. It is a hydrophilic ointment that has properties to draw purulent and mucous contents. Used in an acute period as directed by a doctor.

Vitamins and physiotherapy can be used already when the child recovers.

Alternative treatment and herbal therapy is limited, as 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 onset of timely treatment. Therefore, medical intervention in omphalitis should be based on the complex treatment of surgical complications. Surgical treatment is performed with the appearance of purulent contents in the navel area - primary surgical treatment. If there are other complications, then antibiotic therapy must necessarily be supplemented by surgical intervention. Operation with omphalitis is carried out in order to sanitize the source of infection and drainage.

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

Peritonitis without abdominal abscess may not require surgical intervention, and infection can be controlled with the help of intravenous antibiotics of a wide spectrum of action. The intraperitoneal abscess, confirmed by ultrasonography or laparotomy, should be completely surgically cleaned with further drainage. Intraperitoneal abscess must be sanitized with laparotomy.

Prevention

Prevention of omphalitis is first and foremost the proper care of the umbilical cord of the newborn. To date, this concept includes as little interference from staff and parents, as well as the need for a always dry and clean navel. Therefore, after the discharge home, you do not need to lubricate the navel, but simply bathe the baby in clean boiled water without rubbing the place of healing of the navel. Prevention of complications is important, so when any discharge from the navel appears or the child's general condition is disregarded, it is necessary to consult a doctor.

[21], [22], [23],

Forecast

The prognosis for omphalitis is generally favorable, but the complications, if left untreated, can lead to death rates of up to 7-15%. In 4% of newborns with a localized form of omphalitis, a clinical picture of sepsis develops. Mortality in this case, despite advances in modern medicine, is still high, reaching 30-40% in full-term children, 50% or more in premature babies. Such a forecast once again proves the high need for timely diagnosis of omphalitis.

Omphalitis is a pathology that can be seen, therefore, despite the rapid prevalence of inflammation in omphalitis, it should be diagnosed even by mothers on the basis of a visual assessment of the navel. Untimely diagnosis and treatment of omphalitis leads to disability or death of children. Therefore, a warning, timely diagnosis, effective treatment has not only medical, but also social significance.