Clinical Pediatrics, Volume 13, Issue 9, Pages 767-768. September 1974.
* Formerly, Clinical Fellow, Department of Pediatrics, University of Florida College of Medicine; presently, Director of Intensive Care Nurseries, 
Medical College of Virginia Hospitals, Richmond, Va.
† Professor of Pediatrics and Director of Nursery Intensive Care Unit, University of Florida College of Medicine.
Two premature infants developed septicemia after an elective circumcision employing a plastic bell apparatus. The causative organisms were Proteus and Staphlococcus Aureus, respectively. Both patients responded to proper systemic antibiotic therapy. Physicians are cautioned against circumcising newborn infants who are ill or otherwise at risk.
COMPLICATIONS of elective circumcision, one of the most commonly performed procedures in the United States,1,2 have been reviewed extensively.3,4 The purpose of this report is to alert physicians to the possibility of systemic infection after circumcision in ill or premature infants.
We previously encountered two instances in premature infants who were circumcised with the disposable plastic apparatus currently in use in many hospitals. For those unfamiliar with it, the device consists of a plastic cone or bell which is fitted over the glans. The foreskin is stretched over the bell and a ligature is applied just above the bell. The distal foreskin is then excised, and the cone removed. A plastic ring on the base of the bell is left in situ to fall off in five to seven days.3,5 Complications with this device have included retention of the plastic ring, causing various degrees of indentation to the penile shaft;6–9 localized infections; edema;10 necrosis of the distal penis; and the production of a condition known as concealed penis.
11
Our two cases were encountered within 11 months of each other. Both infants were low birth weight. Each was circumcised electively in the hospital of birth, using standard surgical technique. Patient 2 was circumcised immediately after delivery while having some respiratory difficulty.
Case 1. This 2.0 kg boy was born by normal vaginal delivery on January 23, 1972 to a 17-year-old gravida 2 mother. Membranes were intact until 1½ hours prior to delivery and were ruptured artificially. The Apgar score was 10 at one minute. At age two days, he was circumcised, using a disposable plastic circumcision kit. The procedure was without incident and the infant received routine nursery care. Jaundice was noted the following day (total bilirubin 12.4 mg/100 ml); he ate poorly and was hypothermic. Petechiae and hypotonia appeared A blood smear showedh adequate platelets, and lumbar puncture yielded normal cerebrospinal fluid (CSF). The circumcision site had frank pus around the plastic ring; necrotic tissue was present in this area with induration of the glans and ulceration at the meatus. Cultures of CSF, blood, the wound, and of a voided urine were obtained. The area was debrided.
Because sepsis was suspected, antibiotic therapy was begun. Eight hours later, the platelet count was 11,000, but vital signs were stable and infant appeared more alert. Both the urine and the circumcision site grew out Proteus organisms (greater than 100,000 organisms per ml in the urine and a 4 plus or heavy
growth from the circumcision site). Sensitivity studies were identical from the other two sites. The other cultures failed to grow organisms. The infant improved after treatment, and he was discharged two weeks later. An excretory urogram at the time was normal, and urine cultures failed to grow any organisms. The circumcision site had healed well.
Case 2. This 1.9 kg infant was born December 1, 1972 at a nearby community hospital after 34 weeks gestation to a 24-year-old primaparous mother. She had an uneventful pregnancy, labor, and delivery. The Apgar score was reported to be 10 at one minute. Immediately following birth, circumcision was performed using the disposable plastic apparatus. Grunting respirations with intercostal retractions were noted soon after delivery. At 19 hours of age, because of no improvement in his respiratory condition, he was transferred to the University of Florida Shands Teaching Hospital.
At admission, the patient was an alert premature in mild respiratory distress. Systolic blood pressure with a Doppler device was 68 mm Hg; the respiratory rate was 70 breaths/minute, and the pulse 160 beats/minute. The circumcision site was slightly indurated and the plastic ring with ligature was in place. Within 12 hours, the patients respiratory status had become stable and the respiratory rate was 45 breaths/minute.
The next day the infant was pale, jaundiced, lethargic, and breathing rapidly again. Cultures from the blood and urine from a suprapubic tap were obtained. Antibiotics (ampicillin and kanamycin) were begun because of suspected sepsis. Suppuration was noted at the base of the glans adjacent to the plastic ring; the area was surgically debrided. In the blood smear there were numerous fragmented and irregular erythrocytes. Gross hematuria was present. The prothrombin time was more than 90 seconds (control 12.4 sec.); the partial thromboplastin time was more than 90 seconds (control 30 sec.); and the thrombin time was longer than 60 seconds (control 12.4 sec.) Lumbar puncture yielded CSF containing 110 mm³ ethrocytes and 81 mm³ leukocytes, 64 per cent of which were monocytes and 36 per cent polymorphonuclear cells. The glucose and protein of the CSF were normal. The hematcrit fell from 55 to 43 per cent, and systolic blood pressure byDoppler was now 40 mm HG.
On the fourth day, the patient was given fresh whole heparinized blood and parenteral fluids, adjusted to increase his urinary output. Blood cultures and the urine culture were now reported to be positive for Staphylococcus aureus, coagulase positive. The antibiotics were changed to methicicillin and gentamycin. His condition remained critical until age two weeks, when urinary output increased and the vital signs became more stable. Bilateral pneumonia and congestive heart failure which were major problems during the recover period responded to medical management.. An excretory urogram prior to discharge was normal and cultures of urine weresterile. The circumcision site was now well healed.
Both of these small immature infants had life-threatening infections from which they almost died. It appears that the sites of infection were the open wounds of the circumcision. In Patient 1, this led either to an ascending urinary tract infection by Proteus, or directly to bacteremia. In Patient 2, who was at risk also, because of mild repiratory distress, Staphylococci were recovered from the urine and blood; the infection may have been ascending in nature or led directly to bacteremia.
These cases emphasize the basic rule that no procedure, however, minor, should be considered free from danger. Though it is not clear that the circumcision device used without two cases is particularly prone to induce infectious complications, it is our feeling that early circumcision, regardless of the methods employed is contraindicated in a baby who is ill or otherwise at risk.
This work was supported in part by NIH Grant No. HD0054-12.
plastibellcircumcision device. Med. J. Aust. 1: 1380, 1971.
Correspondence to Donald V. Eitzman, M.D., Box 739; University of Florida Collge of Medicine, Gainesville, Fla. 32610.
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