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Special Statement

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Epidemic Methicillin-Resistant Staphylococcus Aureus:
Dramatically Increased Risk for Circumcised Newborn Boys

Recent reports indicate that community methicillin-resistant Staphylococcus aureus (C-MRSA) now has reached epidemic proportions in many areas1-6 and is a worldwide problem.4-6 Circumcision long has been known to increase the risk of Staphylococcus aureus (SA) infection in newborn boys. The advent of C-MRSA dramatically worsens the risks associated with Staphylococcus infection.

The circumcision wound is a known portal-of-entry for the pathogen and significantly increases circumcised boys' risk. Sauer (1943) reported fatal Staphylococcus broncho-pneumonia after ritual circumcision.7 Thompson et al. (1963,1965) reported that circumcised boys have twice as much SA infection as non-circumcised boys.8,9 Annunziato & Goldblum (1978) reported staphylococcus scalded skin syndrome (SSSS) from infected circumcisions.10 Enzenauer et al. (1985) reported the incidence of Staphylococcus aureus (SA) infection on follow-up among the circumcised males to be more than twice as high as among the non-circumcised males and 5.5 times higher than the females.11 Boys already are at greater risk of SA infection than girls and neonatal circumcision worsens that disadvantage.9,11

SA spreads rapidly through hospital nurseries and newborn boys quickly become colonized with SA.4,9,11-18 Infection frequently affects the diaper and groin area.9,11,18 Boys may also become infected in the home environment after leaving the hospital.15,16,18

In a paper presented to the American Academy of Pediatrics describing the effects of methicillin-resistant Staphylococcus aureus (MRSA) in newborns, Fortunov et al. (2005) report heavy outbreaks of pustulosis in the diaper area along with invasive infections including bacteremia, urinary tract infection, musculoskeletal infections, and empyema (pus in a body cavity).18 Fortunov et al. report MRSA in boys peaks at 7-12 days of age, which would be 6-11 days after non-therapeutic neonatal circumcision.18 The incubation period reported by Fortunov et al.18 is similar to that reported by Cohen (1992).20 No peak was observed in girls.18 Boys had 73 percent of all infections.18 Ten of 12 invasive infections were in boys.18

If the SA is methicillin-resistant, mortality increases,1,19 and death is a possible outcome of MRSA infection. Fortunov et al. reported one male infant death.18 The CDC reports four pediatric deaths in North Dakota and Minnesota.21 The New Scientist reports 800 deaths a year from MRSA in England and Wales.22

There are reports of outbreaks of SA among circumcised boys in hospital nurseries. Zafar et al. reported an outbreak of MRSA in a Virginia nursery.23 Hoffman et al. reported an outbreak of erythromycin-resistant methicillin sensitive Staphylococcus aureus among circumcised boys in a newborn nursery in North Carolina.24 Newsday reported an outbreak of MRSA among circumcised boys in the St. Catherine’s Hospital nursery on Long Island.25

The strictest aseptic surgical technique may not prevent infection of the circumcision wound with SA because the circumcision wound may be infected while the infant patient is in the newborn nursery or in the community after leaving the hospital.

Existing circumcision policy statements by medical societies do not consider the impact of MRSA.26-28 A recent cost-utility study, which found non-circumcision to be the better choice for optimum health and well-being, also did not consider MRSA.29 The advent of MRSA in epidemic proportions increases risks associated with circumcision beyond those previously contemplated and further increases the desirability of the non-circumcision option. MRSA and other antibiotic-resistant varieties of SA, such as vancomycin-resistant Staphylococcus aureus (VRSA), increase risk, including death, to newborn circumcised boys. In view of this increased risk, the policy of offering non-therapeutic neonatal circumcision at parental request, enunciated by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists,30 must be reviewed by medical authorities.

Action Required

Hospital administrators must respond to this new threat to all newborn infants and especially circumcised male infants by limiting circumcisions to those for which there is a clear and present immediate medical indication and by increasing aseptic protocols in newborn nurseries.

Medical practitioners must consider the epidemic status of MRSA and exercise their independent judgment regarding the performance of non-therapeutic neonatal circumcision. There is an ethical duty to not perform scientifically invalid medical treatment, especially when it puts the patient at risk.31 Doctors must act in the best interests of their child-patients regardless of parental requests.32,33 Doctors may conscientiously object to the performance of non-therapeutic circumcision of children.34

References:

  1. Khairulddin N, Bishop L, Lamagni TL, et al. Emergence of methicillin resistant Staphylococcus aureus (MRSA) bacteraemia among children in England and Wales, 1990-2001. Arch Dis Child 2004; 89:378-9. [Full Text]
  2. Gray JW. MRSA: the problem reaches paediatrics. Arch Dis Child 2004;89:297-8. [Full Text]
  3. Dietrich DW, Auld DB, Mermel LA. Community-Acquired Methicillin-Resistant Staphylococcus aureus in Southern New England Children. Pediatrics 2004;113: e347 - e352. [Abstract]
  4. Isaacs D, Fraser S, Hogg G, Li HY. Staphylococcus aureus infections in Australasian neonatal nurseries Arch Dis Child Fetal Neonatal Ed 2004;89:F331 - F335. [Full Text]
  5. Gonzalez BE, Martinez-Aguilar G, Kristina G. Hulten KG, et al. Severe staphylococcal sepsis in adolescents in the era of community-acquired Methicillin-resistant Staphylococcus aureus. Pediatrics 2005;115(3):642-64.[Abstract]
  6. Purcell K, Fergie J. Epidemic of Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections: A 14-Year Study at Driscoll Children’s Hospital. Arch Pediatr Adolesc Med 2005;159:980 - 985. [Abstract]
  7. Sauer LW. Fatal staphylococcus bronchopneumonia following ritual circumcision. Am J Obstetr Gynecol 1943;46:583.
  8. Thompson DJ, Gezon HM, Hatch TF, et al. Sex distribution of Staphylococcus aureus colonization and disease in newborn infants. New Engl J Med 1963: 269;337-41.
  9. Thompson DJ, Gezon HM, Rogers KD, et al. Excess risk of staphylococcus infection and disease in newborn males. Am J Epidemiol 1965;84(2):314-28.
  10. Annunziato D, Goldblum LM. Staphylococcal scalded skin syndrome. A complication of circumcision. Am J Dis Child 1978;132(12):1187-8. [Abstract]
  11. Enzenauer RW, Dotson CR, Leonard T, et al. Male predominance in persistent staphylococcal colonization and infection of the newborn. Hawaii Med J 1985;44(10):389-90, 392, 394-6.
  12. Cook J, Parish JA, Shooter RA: Acquisition of Staphylococcus aureus by newborn babies in a hospital maternity department. Br Med J 1938;1:74-8.
  13. Gillespie WA, Simpson K, Tozer RC. Staphylococcal infection in a maternity hospital. Lancet 1959;2:1075-80.
  14. Hurst V. Transmission of hospital staphylococci among newborn infants. Pediatrics 1960;25:204-14. [Abstract]
  15. Payne MC, Wood HF, Karakawa W, Gluck L. A prospective study of staphylococcal colonization and infections in newborns and their families. Am J Epidemiol 1966:82:305-16.
  16. Gooch JJ, Britt EM. Staphylococcus aureus colonization and infection in newborn nursery patients. Arch Pediatr Adolesc Med 1978;132(9):893-6. [Abstract]
  17. Enzenauer RW, Dotson CR, Leonard T, et al. Increased incidence of neonatal staphylococcal pyoderma in males. Mil Med 1984:149:408-10.
  18. Fortunov RM, Hulten KG, Hammerman WA, et al. Community-Acquired Staphylococcus Aureus Infections in Term and Near Term Previously Healthy Neonates. Presented at American Academy of Pediatrics Annual Conference, Washington, DC, Sunday, October 8, 2005.
  19. Cosgrove SE, Sakoulas G, Perencevich EN, et al. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia; a meta-analysis. Clin Infect Dis 2003;36:53-9. [Medline]
  20. Cohen HA, Drucker MM, Vainer S, et al. Postcircumcision urinary tract infection. Clin Pediatr 1992;31(6):322-4. [Medline]
  21. Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus -- Minnesota and North Dakota, 1997-1999. MMWR Weekly 1999;48(32):707-10. [Full Text]
  22. Vince G. MRSA deaths up 15-fold in a decade. New Scientist, London, February 26, 2004, [Full Text]
  23. Zafar AB, Butler RC, Reese DJ, et al. Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. Am J Infect Control 1995;23(3):200-8. [Medline]
  24. Hoffman KK, Weber DJ, Bost R, Rutala WA. Neonatal Staphylococcus aureus pustulous rash outbreak linked by molecular typing to colonized healthcare workers. Presented at Centers for Disease Control and Prevention 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections. Atlanta, Georgia, March 5-9, 2000.
  25. Rabin R. Mysterious crop of staph: newborns, moms infected after stay at St. Catherine. Newsday, Long Island, New York, October 9, 2003.
  26. American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement. Pediatrics 1999;103(3):686-93. [Full Text]
  27. Council on Scientific Affairs. Report 10: Neonatal circumcision. Chicago: American Medical Association, 1999. [Full Text]
  28. AAFP Commission on Clinical Policies and Research. Position Paper on Neonatal Circumcision. Leawood, Kansas: American Academy of Family Physicians, 2002. [Full Text]
  29. Van Howe RS. A cost-utility analysis of neonatal circumcision. Med Decis Making 2004;24:584-601. [Abstract]
  30. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Fifth Edition, November 2002: p.111.
  31. Opinion E8.20. Current opinions. In: Code of Medical Ethics, Chicago: American Medical Association, 1998. [Full Text]
  32. Committee on Medical Ethics. The law & ethics of male circumcision - guidance for doctors. London: British Medical Association, 2003. [Full Text]
  33. College of Physicians and Surgeons of British Columbia. Infant Male Circumcision. In: Resource Manual for Physicians. Vancouver, BC: College of Physicians and Surgeons of British Columbia, 2004. [Full Text]
  34. Denniston GC, Geisheker JV, Hill G. Conscientious Objection to the Performance of Circumcision of Children. Seattle: Doctors Opposing Circumcision, 2005. [Full Text]

Doctors Opposing Circumcision
Suite 42
2442 NW Market Street
Seattle, Washington 98107-4137
USA
Sunday, October 23, 2005.



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