Aligned with the American Board of Pediatrics format. Authored & peer-reviewed by fellowship-trained clinicians.
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An 8-day-old girl born at 38 weeks gestation presents to the emergency department with a foul-smelling umbilical stump and umbilical stump drainage. She had routine prenatal care and went home from the hospital with her parents after birth. She has not yet established care with her pediatrician. She has lost 5 percent of her birth weight but is waking to feed and making the expected number of wet and dirty diapers. She has not had any fevers, vomiting, diarrhea, or coughing. She is vigorous, and her exam is only remarkable for the above finding. Which of the following is the most appropriate next step?
Omphalitis describes cellulitis of the umbilical stump and the surrounding tissue. The umbilical stump becomes a necrotic nidus of infection that is colonized by the maternal genital tract or the environment. Infection is uncommon in infants with proper newborn care, but when it occurs, it is most commonly caused by Staphylococcus aureus and group A Streptococcus. It is rarely caused by gram-negative enteric bacteria or group B Streptococcus. Omphalitis usually presents before 14 days of life with circumferential erythema of the umbilical stump. Foul drainage and odor are common findings but not exclusive to omphalitis, as many umbilical stumps smell foul without infection and have a small amount of drainage. Antiseptic care at delivery alone is sufficiently protective against omphalitis so that additional treatment is usually not indicated. When this is not available, a single treatment of topical chlorhexidine or alcohol at birth is protective. Risk factors for omphalitis include prematurity and a complicated delivery. When infection occurs, it spreads to the abdominal wall or deeper into the peritoneum, umbilical and portal vessels, and the liver. It can develop into necrotizing fasciitis or sepsis, and these infants have high morbidity and mortality rates. Cultures of the stump drainage should be taken prior to starting antibiotics. Infants with signs of systemic illness (e.g., fever, irritability) should have a full septic workup. Omphalitis is treated with intravenous antibiotics such as nafcillin and gentamicin. Vancomycin is added if there is a high community prevalence of methicillin-resistant Staphylococcus aureus.
Dry cord care (A) describes proper umbilical cord care to reduce the risk of omphalitis after an antiseptic delivery where no additional medication is needed. Oral cephalexin and close outpatient follow-up (C) is inappropriate management despite this infant’s well appearance and lack of systemic symptoms. Sepsis is a common complication of omphalitis, necessitating a more vigorous approach to care. Cephalexin alone also does not provide appropriate coverage for this polymicrobial infection. A topical silver nitrate application (D) is the treatment for an umbilical cord granuloma, not omphalitis. An umbilical cord granuloma presents as a soft, pink, friable mound of granulation tissue at the base of the umbilicus that is typically only identified after cord separation. There may be mild serosanguinous drainage, but there should not be purulent drainage or surrounding erythema and induration, as noted in this patient.
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