Case report
A Preterm neonate of 33 weeks gestation deteriorated on day 2 with septic shock and decreased urine output rapidly over 12 hours. Baby was pale and CRT was prolonged. A Workup was sent and empirical antibiotics were started. Baby needed Inotrope support and improved over next 24-48 hours.
On day 4, redness was seen around the umbilical area and was indurated and tender on palpation.
A diagnosis of Omphalitis was made, swab culture was sent from the base of the cord and Cloxacillin was added. Local dressing was done and local antiseptic ointment was applied.
Over next 2 days, the redness decreased along with induration. Umbilical stump still had not fallen off. Treatment was continued.
After the cord fell off, the redness and induration subsided but pus discharge was seen on manipulation of umbilicus each time. Swab culture was sent. As abdomen was distended, sonogram of abdomen was done to look for internal extension, including screening for collection in fascia and liver. USG was normal. Inj. Vancomycin was added and Cloxacillin was stopped.
Finally, baby showed drastic improvement. Distension of abdomen subsided and umbilicus looked healthy and the baby was discharged. Although no cultures were positive, empirical antibiotics for Staph. aureus was administered for 14 days duration.
Discussion
Although Omphalitis is a superficial infection of umbilical cord, a dreaded scenario is when there is rapid extension of infection to the fascia, muscles and peritoneum of abdomen leading to necrotizing fascitis, myonecrosis and peritonitis. Systemic spread can lead to sepsis and shock rapidly like in this condition.
Common organisms leading to this condition are Staph. aureus, Streptococcus and gram negative organisms like Klebsiella and Proteus. MRSA are also reported in cases of omphalitis. Application of dung, human milk and herbs to cord can lead to infection by Clostridium.
Risk factore for Omphalitis, include Septic delivery, PROM, chorioamnionitis, umbilical vessel catheterization which were all absent in this case. Baby was Low birth weight and was another risk factor for omphalitis.
Mean age of onset in preterm is 3-5 days and in term babies it is 5-9 days.
Treatment: A combination therapy for Gram positive and gram negative agents – Inj. Vancomycin and an Aminiglycoside is preferred drug for empirical use. If extension to internal structures is suspected, addition of metronidazole or clindamycin may be needed.
Surgical consultation must be done for complicated cases.
MD Pediatrics and Fellowship Neonatology, he chooses to stay anonymous. He often writes his views online as well as share few important topics for medical students, doctors and specially parents. He does research in pediatrics.
