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Does an Infected Umbilicus Mean a Sepsis Workup?

April 20, 2022

Editor’s Note: Dr. Morgan Irwin-Weyant is a pediatric resident. She plans to pursue a career in pediatric emergency medicine. I am pleased that she was interested in writing this blog.

-Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

While omphalitis has become uncommon since the advent of antiseptic use in umbilical cord care in the 1960s, there is still fear of the significant morbidity and mortality that might accompany this disorder when it does occur. However, the current prevalence of serious bacterial infection accompanying omphalitis is unknown. Therefore, the best approach to triage, evaluate, and manage neonates presenting with omphalitis has not been established.

When an otherwise healthy and well-appearing 2-week-old infant arrived to our emergency department (ED) with purulent drainage from his umbilicus and surrounding erythema, we immediately obtained blood and site cultures and started empiric antibiotics. Despite the baby continuing to be afebrile and well-appearing, the blood culture was positive for coagulase-negative staphylococcus. We discussed the need for further work-up, including a lumbar puncture, and duration of antibiotic treatment.

At the time, it would have been helpful to have the data from this article being early released in Pediatrics and featured in a video abstract entitled, “Omphalitis and Concurrent Serious Bacterial Infection,” by Dr. Ron L. Kaplan from Seattle Children’s Hospital and colleagues from the Pediatric Emergency Medicine Collaborative Research Committee (10.1542/peds.2021-054189). This retrospective chart review looked at 566 infants diagnosed with omphalitis in 26 pediatric EDs in the US, 1 in Canada, and 1 in Spain from January 1, 2008 to December 31, 2017.

Overall, 95% of these infants were described as well-appearing in the ED, although 11% had a history of fever, and 25% had a history of fussiness or poor feeding. Blood cultures were collected in 83%; although 1.1% demonstrated growth of a pathogen, growth of a contaminant occurred three times more frequently. Over half (58%) had urine cultures and 39% had cerebrospinal fluid cultures; of these, 0.9% were positive for pathogens. Notably, all of the positive urine cultures occurred in infants who were found on ultrasound to have urachal anomalies. Therefore, the authors recommend ultrasound for patients presenting with omphalitis, particularly in the setting of a urinary tract infection. Cultures from the umbilicus were collected in 57% of patients, and these were frequently (85%) positive, with methicillin-sensitive Staphylococcus aureus, methicillin-resistant Staphylococcus aureus, and Escherichia coli being the most commonly found pathogens.

While almost all infants were hospitalized, including 16% to an intensive care unit, only 2.1% had sepsis or shock, 0.4% had severe cellulitis or necrotizing soft tissue infection, and there was one fatality. Given the low incidence of serious bacterial infections in infants presenting with omphalitis, the authors suggest that full sepsis work-up with blood, urine, and cerebrospinal fluid may not be necessary in infants older than 21 days of age who are otherwise afebrile and well-appearing, as per the 2021 AAP guidelines on management of febrile infants.

All who care for neonates should read this paper. It will likely change your practice regarding the evaluation and management of infants presenting with omphalitis. In the future, when another afebrile, well-appearing infant with exam findings suggestive of omphalitis presents to the ED, I will consider an ultrasound for urachal anomalies and feel confident forgoing a lumbar puncture.

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