Download Neonatal omphalitis: A review of its serious complications

Acta Pædiatrica, 2006; 95: 519 /522
CLINICAL OVERVIEW
Neonatal omphalitis: A review of its serious complications
NIA FRASER1, BRIAN W. DAVIES1 & JONATHAN CUSACK2
Departments of 1Paediatric Surgery and 2Neonatal Medicine, Queens Medical Centre, Nottingham, UK
Abstract
Until the advent of aseptic deliveries and aseptic umbilical cord care, many deaths occurred from umbilical infections.
Omphalitis is a localized infection of the umbilical cord stump, most commonly caused by a single organism, which usually
responds well to appropriate antibiotics. Umbilical sepsis is relatively uncommon in the developed world but is endemic in
less-developed regions. Complications of omphalitis are exceedingly rare, but potentially catastrophic. Many of these babies
will require surgical intervention. This paper aims to review the serious complications of omphalitis and how these should be
managed.
Conclusion: It is important to be aware of the rare but potentially lethal complications of omphalitis. Prompt recognition of
serious sequelae is crucial for survival.
Key Words: Necrotizing fasciitis, omphalitis, peritonitis, puourachus, umbilical sepsis, urachal remnant
‘‘The incidence of fatal sequelae in the cases that do
occur is sufficiently great to merit serious consideration of the disease by obstetrician, paediatrician
and surgeon.’’
J. W. Chamberlain, 1936 [1]
The normal umbilical cord separates between 5 and
8 d after a vaginal delivery and about a day later
following Caesarean section. Separation is probably
initiated by thrombosis of the umbilical vessels, and
contraction of certain proteins within their wall.
Necrosis of the umbilical cord stump, by phagocytic
neutrophils, occurs followed by epithelialization of the
cord stump. The umbilicus may become colonized by
bacteria from the maternal genital tract or from the
environment soon after birth [2]. Cord infections
delay or prevent obliteration of the umbilical vessels.
Pathogens are thereby provided direct access to the
systemic circulation.
The estimated incidence of omphalitis in hospitalized newborns in the developed world is around 0.7%
[3]. In developing countries, it may be as high as
6.18% [4]. There is a male preponderance.
The most frequently encountered risk factors for
the development of omphalitis in babies are protracted labour, non-sterile delivery, septic delivery as
suggested by prolonged rupture of the fetal membranes or maternal infection, prematurity, low birthweight (B/2500 g), and umbilical catheters [4/6].
Some cases of omphalitis occur as a result of
inappropriate cord handling, for example cultural
application of substances such as tobacco ash [7].
Genetic defects in contractile proteins have also been
implicated and, in some, immunological factors may
play a part. Such abnormalities include defects in
leukocyte adhesion molecules, neutrophil mobility
and interferon production [8].
Omphalitis is characterized by periumbilical oedema, erythema, and tenderness with or without
discharge [8]. Three categories are recognized based
on the extent of infection [5]: 1) purulent discharge
only; 2) cellulitis and lymphangitis of the abdominal
wall; and 3) inflammation extending into the subcutaneous fat and deep fascia.
The organisms responsible depend on geographical
location. In the developed world, common pathogens
include Staphylococcus aureus , Staphylococcus epidermi-
Correspondence: N. Fraser, Department of Paediatric Surgery, Queens Medical Centre, Derby Road, Nottingham NG7 2UH, UK. Tel: /44 (0)115 924
9924. Fax: /44 (0)115 970 9929. E-mail: [email protected]
(Received 19 January 2006; accepted 16 February 2006)
ISSN 0803-5253 print/ISSN 1651-2227 online # 2006 Taylor & Francis
DOI: 10.1080/08035250600640422
520
N. Fraser et al.
dis , groups A and B Streptococcus, Escherichia coli ,
Klebsiella , Pseudomonas , and Clostridium difficile . Tetanus is an important pathogen in developing countries. Epidemics with organisms such as group A
Streptococcus and Staphylococcus species may be implicated if there are clusters of babies presenting with
omphalitis in nurseries [9].
In general, localized spread produces abdominal
wall complications, while extension along umbilical or
portal vessels results in intra-abdominal pathology.
Babies in both groups are at risk of escalating systemic
sepsis, and some may be moribund when first seen by
a clinician.
Serious complications of omphalitis that have been
reported are listed in Table I. The typical clinical
features of each and their management are reviewed.
Septicaemia
The signs of omphalitis-related neonatal infection are
often very non-specific. Temperature instability, poor
handling or abdominal distension should raise suspicion of sepsis. Systemic sepsis may lead to the seeding
of septic emboli, causing problems such as abscesses,
septic arthritis, meningitis [10] and bacterial endocarditis. Multiorgan failure and disseminated intravascular coagulopathy may result. The mortality rate
for neonatal sepsis varies according to gestational age,
but may be as high as 30% in very-low-birthweight
(VLBW) babies [11].
Necrotizing fasciitis (NF)
NF is a very rare, highly lethal, rapidly progressing
soft tissue infection along an oedematous plane above
the deep fascia. It is one of the most commonly
reported major complications. Necrosis may spread to
involve skin overlying the chest wall, flanks and
scrotum, and typically mixed aerobes and anaerobes
are isolated [12,13]. The baby initially appears
deceptively well [7], but systemic toxicity soon
escalates leading to a mortality rate of between 50
and 87.5% [6,14].
Oedema of the umbilicus and peau d’orange
appearance, which implies obstruction of the deep
Table I. Major complications of neonatal omphalitis.
Complication
Septicaemia
Necrotizing fasciitis
Abscesses:
Retroperitoneal, pelvic, cutaneous, hepatic
Peritonitis
Adhesive small bowel obstruction
Spontaneous small bowel evisceration
Hepatic vein thrombosis
lymphatics, is a warning sign of a salvageable situation. If unrecognized, the skin very quickly forms a
purplish-blue discolouration pathognomonic of NF,
then sloughs. Very rarely, gangrene may extend
through the rectus abdominis and peritoneum, and
even involve the adjacent bowel [7]. It is important to
note that crepitus is not a typical feature of umbilical
NF.
Survival depends on prompt recognition of early
signs, and aggressive resuscitation followed by extensive surgical debridement. This procedure involves
excision of all necrotic material, until healthy bleeding
tissue is reached [15]. The importance of the excision
of umbilical vessels has been emphasized by Dinari
[16] and Kosloske [13], even if they appear macroscopically intact [14]. Multiple debridements may be
necessary [17], and the resulting wounds are left
open. Drains and skin grafts are sometimes required.
The rapid progression of untreated disease is aided by
bacterial release of collagenase and toxins, and polymicrobial infections carry the worst prognosis. Some
authors have suggested that the use of hyperbaric
oxygen may minimize disease progression [14]. Immunoglobulin has also been used as a treatment
modality by some [15].
Peritoneal complications
In the neonate, the umbilical vein is separated from
the peritoneal cavity by only a thin layer of areolar
tissue and a single layer of peritoneum. This makes
the abdominal cavity vulnerable in the face of
umbilical sepsis. If the umbilical vein becomes infected, peritoneal contamination often becomes generalized because the neonatal omentum is small and
cannot effectively wall off infection. Babies with
omphalitis complicated by peritonitis are unable to
feed and may have bilious vomiting. Diarrhoea is
present in 50% of cases. The neonate appears septic,
and the abdomen is distended and tender. Laparotomy is usually performed if other pathologies such as
malrotation and volvulus cannot be excluded. During
the procedure, all intraperitoneal pus is evacuated and
involved umbilical vessels excised. Interestingly,
Holve [18], Duggen [19] and Bell [20] described
several babies with this condition who were managed
conservatively with parenteral antibiotics. The
authors stress that a ‘‘surgical’’ abdomen must first
be excluded. Chadwick successfully treated one baby
with intraperitoneal followed by intravenous antibiotics [21]. Adhesive small bowel obstruction was
reported as a late complication by Ameh in a 75-dold boy with previous neonatal omphalitis [22]. At
laparotomy, there were multiple adhesions between
loops of the small bowel and the anterior abdominal
wall in the region of the umbilicus.
Neonatal omphalitis
Infection of urachal remnant
The fetal urachus develops from the apex of the
ventral cloaca and is a tubular structure connecting
the bladder to the umbilicus. Normally, as the bladder
descends behind the pelvic brim, the urachus elongates then undergoes luminal obliteration. Incomplete
obliteration may lead to the formation of urachal cysts
or communication with the umbilicus or bladder.
Babies with a urachus communicating with an infected umbilicus may present with unresolving omphalitis and, in extreme cases, pus will fill this
structure and form a urachal abscess (pyourachus).
Macmillan reported two babies with perforation of
pyourachus and resultant peritonitis, both of whom
survived following abscess drainage and excision of
urachal remnants [23].
521
utilizing an abdominal incision if the collection is
more anterior. The cavity is lavaged and drains may
be beneficial.
Hepatic complications
The hepatic portal vein may become obstructed due
to ascending infection and thrombosis (portal cavernoma). Varices may develop and require sclerotherapy, and portal-systemic shunts may be necessary
[25]. Secondary biliary tract obstruction has also been
reported [26]. Hepatic abscesses may occur, and
spontaneous rupture and necrosis of the entire left
lobe has been described [22]. These abscesses are
managed by extraperitoneal drainage or laparotomy.
Spontaneous bowel evisceration
Abscesses
Superficial cutaneous abscesses may be confined to
the umbilical region or occur in distant sites due to
haematogenous seeding of septic emboli.
Intrabdominal abscesses may arise if bacteria originating in the umbilicus invade the umbilical artery.
This vessel joins the iliac artery in the pelvis, and
infection may extend along these structures to form
retroperitoneal or pelvic abscesses (Figure 1). Depending on the exact location, the baby may present
with a lower abdominal mass or inguinoscrotal swelling [16]. Feo reported a neonate with a retroperitoneal abscess, which extended into the gluteal region
[24]. Following diagnosis, surgical drainage is best
performed at the site where the abscess points, or by
Umbilical vein
Umbilical cicatrix
Umbilical artery
Urachus
Bladder
Figure 1. Anatomy of the anterior abdominal wall as seen from
inside the peritoneal cavity
This is extremely rare and occurs as a result of the
breakdown of fascia forming the umbilical cicatrix
and overlying skin. The eviscerated bowel may be
strangulated, resulting in gangrene [22]. Necrotic
bowel should be resected, and the remainder cleaned
and returned to the peritoneal cavity. The umbilicus is
then reconstructed.
Summary
Omphalitis is a potentially lethal infection and should
never be underestimated. Neonates, in particular
those born prematurely, have not yet reached immunological maturity [20]. For this reason, in part, a
minor umbilical infection may rapidly lead to a serious
complication. The umbilical vein provides a direct
route for bacteria to the liver, and the umbilical
arteries and urachus are pathways to the pelvis. In
order to prevent complications associated with omphalitis, a baby with periumbilical cellulitis should be
admitted for intravenous antibiotics effective against
Staphylococcus aureus , streptococci and Gram-negative
rods. If infection persists despite appropriate treatment, an underlying infective focus such as a patent
urachus should be sought.
The principles of the management of complicated
omphalitis include ventilatory support and fluid
resuscitation to correct dehydration, acidosis and
associated problems. A Gram stain and culture of
umbilical exudate or necrotic material should be
performed prior to the administration of systemic
antibiotics.
The early recognition of umbilical oedema and
peau d’orange is vital for the baby’s survival in cases of
NF. This sign, or the blue discolouration pathognmonic of NF, should prompt surgical referral for
extensive debridement. Hyperbaric oxygen and immunoglobulin could be considered if available.
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N. Fraser et al.
Suspected peritonitis usually warrants laparotomy,
and abscesses and urachal remnants should be
drained or excised as appropriate.
Cord infections in developing countries can be
prevented through increasing access to tetanus toxoid
immunization during pregnancy, promoting clean
cord care and reducing harmful cord applications.
Garner et al. reported a successful intervention
programme in Papua New Guinea, which included
the provision of both health education and umbilical
cord care packs. This led to a decline in deaths from
neonatal omphalitis [27].
A recent Cochrane systematic review was unable to
make recommendations for best practice regarding
cord care, but suggested that the use of topical
antiseptics in higher-risk preterm infants may be
beneficial [28].
Vigilance in identifying the major complications of
neonatal omphalitis and early referral to specialist
centres is vital for the survival of these babies.
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