Doctors Opposing Circumcision
Special Statement

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

Pryles (1958) reported that Staphylococcus aureus is a bacterium that has the ability to evolve and develop resistance to antibiotics in wide use.1 Jevons (1961) confirmed this finding.² Curran (1980) reported S. aureus produces a tissue-destroying exotoxin.³ After six decades of antibiotic use, forms of S. aureus have evolved that are resistant to most common antibiotics, and this has become an important public health problem.⁴ These are given the name "methicillin-resistant Staphylococcus aureus" (MRSA). MRSA was once found primarily in hospitals, but new strains have entered the community.⁴ These new strains have acquired several new virulence factors.⁴ The existence of these virulent antibiotic-resistant pathogens pose serious problems for clinical management of infected patients.⁴

Recent reports indicate that community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) now has reached epidemic proportions in many areas and has become a worldwide problem.^4-12 Kuehnert et al. (2006) estimate, based on samples obtained in the National Health and Nutrition Examination Survey, that 32.4 percent of the U.S. population are colonized with S. aureus.¹³ Circumcision long has been known to increase the risk of S. aureus infection in newborn boys. The advent of epidemic CA-MRSA dramatically worsens the risks associated with Staphylococcus infection because:

• the presence of CA-MRSA in epidemic proportions increases the chance of an infant being infected with MRSA by caregivers.
• the threat to health is escalated beyond that posed by methicillin-sensitive Staphylococcus aureus (MSSA) if an infant should be infected.
• the risk of death is increased.

This statement reviews the literature regarding MRSA with an emphasis on the risk to newborn circumcised boys.

The Circumcision Wound as Portal-of-Entry for Staphylococcus aureus

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.¹⁴ Isbester (1959) identified circumcision as a factor in lowering resistance.¹⁵ Thompson et al. (1963,1965) reported that boys have about twice the infection rate of girls, and circumcised boys have twice as much SA disease as non-circumcised boys (26 percent compared to 13 percent).^16,17 Kirpatrick & Eitzman (1974) reported a case of staphylococcal septicemia after neonatal circumcision.¹⁸ Annunziato & Goldblum (1978) reported staphylococcal scalded skin syndrome (SSSS) from infected circumcisions.¹⁹ Woodside (1980) reported a case of staphylococcal necrotizing fasciitis after "routine" non-therapeutic circumcision.^20,21 Curran & Al-Salihi (1980) reported that male newborns have 5.5 times as much general exfoliative disease (SSSS) as girls.³ 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 4 times higher than females.²² Stranko et al. (1986) reported staphylococcal impetigo in newborn circumcised males.²³ Bliss et al. (1997) reported two cases of staphylococcal necrotizing fasciitis after circumcision.²⁴ Boys already are at greater risk of SA infection than girls and neonatal circumcision worsens that disadvantage.^{3, 14,17,20-24}

Initial presentation of post-circumcision staphylococcal necrotizing fasciitis Patient after surgical debridement of infected tissue

Transmission of Infection

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. SA spreads rapidly through hospital nurseries and newborn boys quickly become colonized with SA.^{1,3,9,17,22-30} Infection frequently affects the diaper and groin area.^16,22,29 Gooch & Brit (1978) reported that 24 percent of newborns are colonized at time of discharge and, of these, 2 percent have an infection.²⁹ Enzenauer et al. (1984) commented, "Circumcision, by its very nature, requires more staff-person 'hands-on' contact, both during the procedure and during preoperative and postoperative care," so circumcised boys are more likely to be infected.³⁰ Boys may also become infected in the home environment after leaving the hospital.^28,31

Previous Nursery Outbreaks

There are numerous reports of outbreaks of SA among circumcised boys in hospital nurseries. Remington & Klein reported 25 outbreaks from 1961 to 1987 in U.S. hospital nurseries.³² Zafar et al. (1995) reported an outbreak of MRSA in a Virginia nursery.³³ Hoffman et al. (2000) reported an outbreak of erythromycin-resistant methicillin sensitive Staphylococcus aureus among circumcised boys in a newborn nursery in North Carolina.³⁴ Rabin (2003) reported an outbreak of MRSA among circumcised boys in the St. Catherine’s Hospital nursery on Long Island.³⁵ Saiman et al. (2003) reported the outbreak of MRSA in a New York City newborn nursery.³⁶ Nabiar et al. (2003) reported the outbreak of MRSA in a Washington, DC, newborn intensive care unit with one death.³⁷ Bratu et al. (2005) reported an outbreak of MRSA in the nursery of a New York City hospital and said "the introduction of CA-MRSA strains into neonatal units represents an especially serious challenge."³⁸

Bratu et al. (2005) identify surgical operations as a risk factor for MRSA infection in the newborn.³⁸ Other researchers identify male neonatal circumcision as a specific risk factor.^39,40 Nguyen et al. (2007) report that circumcised newborn boys are twelve times more likely to get a MRSA infection than a non-circumcised boy.⁴⁰

Manifestations of Infection with MRSA

Some strains of MRSA produce fulminant infection that may progress rapidly to death.⁴ Isaacs et al. (2004) report that osteomyelitis and/or septic arthritis occurs in connection with MSSA, but more skin infection and cellulitis occurs in connection with MRSA.⁹ Zetola et al. (2005) report more outbreaks of skin infections, including epidemic furunculosis with possible septic shock, and cases of severe invasive pulmonary infections, including necrotizing pneumonia, in young, otherwise healthy people.⁴

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).³¹ 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.³¹ The incubation period reported by Fortunov et al.³¹ is similar to that reported by Cohen (1992) for post-circumcision urinary tract infections.⁴¹ No peak was observed in girls.¹¹ Boys had 73 percent of all infections.³¹ Ten of 12 invasive infections were in boys.³¹

MRSA is causing new and previously unknown diseases in infants and young children. Kikuchi et al. (2003) reported a new disease called neonatal toxic shock syndrome-like exanthematous disease (NTED).⁴⁰ Adem et al. (2005) report three fatal cases of staphylococcal Waterhouse–Friderichsen Syndrome in young girls.⁴³

Mortality

Staphylococcus aureus infection was often fatal in the pre-antibiotic era.⁴⁴ If the SA is methicillin-resistant, mortality increases,^4,5,45,46 and death is a possible outcome of MRSA infection. Pryles (1958) reported nine deaths among 24 infants with staphylococcal pneumonia for a mortality rate of 37.5%.¹ Thompson et al. (1963,1965) report a higher mortality rate for males.^16,17 Fortunov et al. (2005) report one male infant death.³¹ The CDC (1999) reports four pediatric deaths in North Dakota and Minnesota.⁴⁵ Isaacs et al. (2004) report a mortality rate of 24.6 percent for MRSA-infected newborn babies as compared with 9.9 percent for MSSA-infected babies.⁹ Healy et al. (2004) report a mortality rate of 38 percent among MRSA infected newborn infants.⁴⁶ Vince (2004) reports 800 deaths a year from MRSA in England and Wales.⁴⁷ Noskin et al. (2005) report 12,000 inpatient deaths a year in U.S. hospitals caused by MRSA.⁵⁰ According to Noskin et al., a patient with MRSA infection is five times more likely to die in hospital.⁵⁰ Templeton (2005) reported that, at Great St. Ormond Street Hospital in England, out of 20 children with MRSA infection aged three-years or younger, four died, including one boy, born healthy, who died from MRSA infection 36 hours after birth,⁵¹ for a mortality rate of 20 percent.

Costs

Noskin et al. (2005), using data from the National Inpatient Survey, reports that the hospital stay and costs for adult patients triple when the patient has a MRSA infection.⁵⁰ No data are available for infant or child patients.

Epidemiology

MRSA infection is an emerging epidemic disease. MRSA infection is not a reportable disease, consequently, epidemiological data have not been collected.

Outmoded Medical Society Statements.

Circumcision policy statements by medical societies do not consider the impact of epidemic MRSA, so their recommendations are no longer appropriate.^52-56 In fact, the American Academy of Pediatrics has issued no statement to its members on the treatment of MRSA.

Even though a recent cost-utility study did not consider the advent of MRSA, it still found non-circumcision to be the better choice for optimum health and well-being.⁵⁷ Non-circumcision was the preferred medical choice prior to the arrival of MRSA in epidemic proportions,^{52 56 57} and is even more so today. The advent of MRSA in epidemic proportions increases risks associated with male neonatal 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.^4,31,43,44 In view of this increased risk, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists should terminate their policy, most recently affirmed in 2002,⁵⁸ of offering elective medically-unnecessary non-therapeutic neonatal circumcision at parental request.

Management of MRSA infection

Bliss et al. (1997) recommend early diagnosis, followed by rapid and aggressive treatment for a successful outcome.²⁴ Professors Bamberger & Boyd (2005) provide a recent guidance on treatment.⁵⁹ Kaplan (2005) also discusses treatment options.⁶⁰ Mortality remains high even with the best treatment.⁵⁹

Action Required

Doctors Opposing Circumcision consistently has advised parents that genital integrity (non-circumcision) is most likely to produce the highest state of health and well-being^56,57 and is the preferred medical option for newborn boys.⁶¹ The arrival of community MRSA in epidemic proportions adds additional force to that recommendation.

Public health officials should act to suspend the performance of medically-unnecessary non-therapeutic circumcision of boys.

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 decline and avoid scientifically invalid treatment, especially when it puts the patient at risk.⁶⁰ Doctors must act in the best interests of their child-patients regardless of parental requests.^63-65 Doctors may conscientiously object to the performance of non-therapeutic circumcision of children.^64-66

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