Pediatric Infectious Disease, Volume 5, Issue 5, Pages 597-599. September 1986.
Department of Pediatric Subspecialities, Geisinger Clinic, Danville, PA
Pediatric Infectious Disease, Volume 5, Issue 5, Pages 597-599. September 1986.
Department of Pediatric Subspecialities, Geisinger Clinic, Danville, PA
Circumcision remains the most common surgical procedure in the United States, despite any clear medical indication for its use. Usual methods of circumcision include the Gomco clamp and the plastic bell clamp. There also is renewed interest in the Mogen clamp, which was designed in 1954 and has a low complication rate.1 Because the plastic bell clamp method is easy to perform, many doctors favor its use despite many complications that have been associated with its use. These include passive and prolonged retention of the device on the penis that has resulted in constriction of the glans,2 hemorrhage, local infection3 and septicemia.
We report the possible association of bullous and non-bullous impetigo with use of the plastic bell clamp method of circumcision. To our knowledge this association has not been reported previously.
Subjects and methods. Between July 1 and August 30, 1982 and between August 1 and September 30, 1984, eight cases of impetigo in infants younger than 1 month of age were reported to infection control personnel at 
Geisinger Medical Center. (Table 1). These cases were subsequently reviewed in a case-controlled study, comparing method of circumcision, age at onset of symptoms, nursery personnel involved in the circumcision. And in the care of the infant, perinatal history, physical examination at birth and prior to discharge from the nursery, includingtherapy and outcome.
The investigators defined bullous impetigo as a pustular, vesicular lesion surrounded by an erythematous base, located in the diaper area or lower abdomen. Nonbullous impetigo was defined as raised erythematous lesions with honey-colored crusts on the face, fingers or about the mouth and nose.
Results. Four cases of bullous impetigo and two cases of nonbullous impetigo were reported between 7 and 22 days after circumcision by the plastic bell clamp technique. That method of circumcision was discontinued until August and September, 1984, which time two additional cases occurred when a pediatrician, new to our institution, began using the plastic bell clamp method of circumcision. During that period 25 circumcisions were performed in the newborn nursery using this technique. No circumcisions were performed using the Gomco clamp during the same two time periods.
All infants with impetigo were full-term white males. Pregnancy, labor and delivery were uncomplicated. At the time of discharge from our nursery all had a normal physical examination without evidence of cutaneous infection.
Circumcision in all cases was by the plastic bell clamp method performed under sterile conditions using iodophor preparation and sterile gowns, gloves, and masks. Vaseline® gauze was not used on the two infants who had impetigo in 1984. Cultures of plastic bell clamps, Vaseline® gauze, nursery personnel and other infants were performed and no source of infection was identified.
The pediatric house staff performed the circumcisions under the supervision of a staff pediatrician. No consistent pattern as to who performed the circumcision was noted, and on one physician was directly involved with more than two infants.
All infants were cared for in two adjoining nurseries using cohorting techniques by the same nursery personnel. There were no differences in lengths of hospitalization, feeding methods or instructions to parents regarding circumcision care and bathing, and all were private patients with similar socioeconomic status.
Two infants required admission to our Neonatal Intensive Care Unit for suspected staphylococcus scalded skin sydrome. They were treated with intravenously administered methicillin for 10 days. The other six infants were treated with dicloxacillin given orally as outpatients.
Five patients had Staphylococcus aureus cultured from the impetiginous area. Another infant had gram-positive cocci in clusters observed on a Gram stain smear of a lesion. Phage typing performed on 75% of the S. aureus isolates from infants and from nursing personnel failed to reveal a consistent pattern.
Since September 1982, more than 1500 circumcisions had been performed at our institution using the Gomco clamp. Two cases of impetigo have occurred in that group. Both were bullous impetigo and S. aureus was isolated from both patients; the two patients were in the newborn nursery at the same time. No other cases of impetigo or staphylococcus diseases have occurred in our newborn nursery. No cases of impetigo have occurred in newborn females at our institution in at least five years.
| TABLE 1 | ||||
|---|---|---|---|---|
| Cases of impetigo in newborn infants circumcised by the Plastibell® technique hr(); | ||||
| Date of Circumcision by Plastibell® | Date of Discharge from Nursery | Date of Diagnosis | Description | Culture of Skin Lesions |
| hr(); | ||||
| 6/29/82 | 7/1/82 | 7/12/82 | Bullous lesion of buttocks | 7/12, moderate Staphylococcus aureus |
| 6/29/82 | 7/1/82 | 7/21/82 | Impetigo, nonbullous | Not done |
| 6/30/82 | 7/2/82 | 7/7/82 | Impetigo, nonbullous, chin | 7/7/82, chin culture, N.G. |
| 6/30/82 | 7/2/82 | 7/8/82 | Bullous lesion, thigh | 7/8 Many Staphylococcus aureus |
| 7/7/82 | 7/9/82 | 7/17/82 | Bullous lesions of buttock, thigh and back | 7/17, moderate Staphylococcus aureus, few Acinetobacter, nonhemolytic streptococci |
| 7/22/82 | Recurrent bullae, thigh | 7/22/82, Staphylococcus aureus | ||
| 7/22/82 | Recurrent bullae, thigh | 7/22, Staphylococcus aureus | ||
| 8/9/92 | Recurrent bullae, abdomen, thigh | 8/9, Staphylococcus aureus | ||
| 9/10/82 | New bullous lesions, thigh | 9/10, Staphyloccoccus aureus | ||
| 9/19/82 | New lesion | |||
| 9/21/82 | Normal examination | |||
| 8/13/82 | 8/15/82 | 8/26/82 | Bullous lesions, diaper area | 8/26, gram + cocci |
| 8/15, discharge from nursery, Staphylococcus aureus from unbilicus and nasopharygneal culture | ||||
| 8/10/84 | 8/15/84 | 8/29/84 | Non-bullous lesions, faceneck | 8/29/04, face culture, moderate Staphylococus aureus |
| 8/17/84 | 8/15/84 | 8/29/84 | Bullous lesios, abdomen → nipple | 9/2/84, Staphylococcus aureus |
Discussion. Neonatal circumcision has been associated with numerous complications. Serious infections such as necrotizing fasciitis,4 generalized sepsis,5 meningitis6 and osteomyelitis7 have been reported. Other noninfectious complications include urinary retention, meatitis, chordee, cysts, lymphedema, urethral fistulas and necrosis of the glans or entire penis.6
Staphylococcus scalded skin sydrome has been reported as a complication of circumciion.8 In three cases of staphylococcus scalded skin syndrome, S. aureus was recovered from cultures of the nasopharynx, throat, conjunctivae or circumcised area. Staphylococcus scalded skin sydrome is caused by release of an exotoxin that produces an intraepidermal separation of tissue. The result is erythematous, tender and desquamating areas of skin, usually with a positive Nikolskys sign.
In our search of the medical literature we have not found an association between circumcision and the occurrence of bullous or nonbullous impetigo. Bullous impetigo is a local form of disease caused by the same organism that produces exfoliation.
Address for reprints: Michael E. Ryan, D.O., Department of Pediatric subspecialities, Geisinger Clinic, Danville, PA 17822.
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