Circumcision and MRSA

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Pustular infections due to Staphylococcus aureus in the newborn nursery are preventable.

Approximately 4% of all newborns develop an infection in the first 30 days of life. Of these, pustulosis is the second-most common (after nonpneumonia respiratory tract infections), occurring in about 1 in every 100-200 newborns with a peak onset at 10-15 days of life. Most of these infections are due to S. aureus, and increasingly, methicillin-resistant S. aureus (MRSA).

Indeed, outbreaks of neonatal pustular disease should prompt concern about MRSA in the community. Colonization with S. aureus requires very little exposure. The problem can often be traced to crowding and failures of standard infection control practices in the newborn nursery, along with two other specific recently identified risk factors: circumcision and the use of multidose lidocaine vials.

A case-control study investigated 11 newborns who had onset of MRSA skin and soft-tissue infection within 21 days after discharge from a well-infant nursery at a community hospital over an 8-month period. All were term male infants with pustular-vesicular lesions in the groin, Dr. Dao Nguyen and associates at the Centers for Disease Control and Prevention reported (Infect. Control Hosp. Epidemiol. 2007;28:406-11).

Risk factors associated with the MRSA infections were length of stay, circumcision in the nursery, and receipt of lidocaine injections used to anesthetize for the circumcision procedure. Inspection revealed uncovered circumcision equipment, multiple-dose lidocaine vials, and inadequate hand hygiene practices.

Nineteen cases of MRSA infection were reported in neonates born at Beth Israel Deaconess Medical Center in Boston. Of the 19 infants who have become ill with the drug-resistant staphylococcal infection, 15 have been boys, the Boston Public Health Commission reported. Violations of standard infection control practices related to circumcision and postprocedure care were identified as contributing factors.

A literature review of 10 articles reporting on staphylococcal colonization and infection in the newborn period revealed that male infants have a greater risk than do female infants, and that the male to female ratio is even higher in studies where most of the boys are circumcised as infants (Clin. Pediatr. 2007;46:356-8).

But the answer to the neonatal staphylococcal problem is not to stop circumcising babies. Policies and attitudes toward circumcision are currently being revisited. After a decade or so in which a large body of evidence indicating the procedure reduces the risk for the development of a variety of sexually transmitted diseases was largely ignored, the American Academy of Pediatrics is reviewing its policy on the medical benefits of the procedure.

What's needed is better attention to surgical technique and hygiene during circumcision procedures, along with the use of single-dose lidocaine vials.

For newborns who do develop pustular disease in the diaper area, lower abdomen, or any other area, the approach to management varies considerably. Some infants are hospitalized and treated systemically while others are managed with local or topical therapy. An individualized approach would appear necessary as the spectrum of clinical disease is broad. First, the child should be evaluated for other possible etiologies.

If staphylococcal disease is suspected, the presence or absence of systemic signs, abscess, or local cellulitis will help determine whether systemic therapy is needed or if initial local management is appropriate. In all cases, close follow-up is needed to ensure that resolution occurs.

[email protected]

Pustular infections due to Staphylococcus aureus in the newborn nursery are preventable.

Approximately 4% of all newborns develop an infection in the first 30 days of life. Of these, pustulosis is the second-most common (after nonpneumonia respiratory tract infections), occurring in about 1 in every 100-200 newborns with a peak onset at 10-15 days of life. Most of these infections are due to S. aureus, and increasingly, methicillin-resistant S. aureus (MRSA).

Indeed, outbreaks of neonatal pustular disease should prompt concern about MRSA in the community. Colonization with S. aureus requires very little exposure. The problem can often be traced to crowding and failures of standard infection control practices in the newborn nursery, along with two other specific recently identified risk factors: circumcision and the use of multidose lidocaine vials.

A case-control study investigated 11 newborns who had onset of MRSA skin and soft-tissue infection within 21 days after discharge from a well-infant nursery at a community hospital over an 8-month period. All were term male infants with pustular-vesicular lesions in the groin, Dr. Dao Nguyen and associates at the Centers for Disease Control and Prevention reported (Infect. Control Hosp. Epidemiol. 2007;28:406-11).

Risk factors associated with the MRSA infections were length of stay, circumcision in the nursery, and receipt of lidocaine injections used to anesthetize for the circumcision procedure. Inspection revealed uncovered circumcision equipment, multiple-dose lidocaine vials, and inadequate hand hygiene practices.

Nineteen cases of MRSA infection were reported in neonates born at Beth Israel Deaconess Medical Center in Boston. Of the 19 infants who have become ill with the drug-resistant staphylococcal infection, 15 have been boys, the Boston Public Health Commission reported. Violations of standard infection control practices related to circumcision and postprocedure care were identified as contributing factors.

A literature review of 10 articles reporting on staphylococcal colonization and infection in the newborn period revealed that male infants have a greater risk than do female infants, and that the male to female ratio is even higher in studies where most of the boys are circumcised as infants (Clin. Pediatr. 2007;46:356-8).

But the answer to the neonatal staphylococcal problem is not to stop circumcising babies. Policies and attitudes toward circumcision are currently being revisited. After a decade or so in which a large body of evidence indicating the procedure reduces the risk for the development of a variety of sexually transmitted diseases was largely ignored, the American Academy of Pediatrics is reviewing its policy on the medical benefits of the procedure.

What's needed is better attention to surgical technique and hygiene during circumcision procedures, along with the use of single-dose lidocaine vials.

For newborns who do develop pustular disease in the diaper area, lower abdomen, or any other area, the approach to management varies considerably. Some infants are hospitalized and treated systemically while others are managed with local or topical therapy. An individualized approach would appear necessary as the spectrum of clinical disease is broad. First, the child should be evaluated for other possible etiologies.

If staphylococcal disease is suspected, the presence or absence of systemic signs, abscess, or local cellulitis will help determine whether systemic therapy is needed or if initial local management is appropriate. In all cases, close follow-up is needed to ensure that resolution occurs.

[email protected]

Pustular infections due to Staphylococcus aureus in the newborn nursery are preventable.

Approximately 4% of all newborns develop an infection in the first 30 days of life. Of these, pustulosis is the second-most common (after nonpneumonia respiratory tract infections), occurring in about 1 in every 100-200 newborns with a peak onset at 10-15 days of life. Most of these infections are due to S. aureus, and increasingly, methicillin-resistant S. aureus (MRSA).

Indeed, outbreaks of neonatal pustular disease should prompt concern about MRSA in the community. Colonization with S. aureus requires very little exposure. The problem can often be traced to crowding and failures of standard infection control practices in the newborn nursery, along with two other specific recently identified risk factors: circumcision and the use of multidose lidocaine vials.

A case-control study investigated 11 newborns who had onset of MRSA skin and soft-tissue infection within 21 days after discharge from a well-infant nursery at a community hospital over an 8-month period. All were term male infants with pustular-vesicular lesions in the groin, Dr. Dao Nguyen and associates at the Centers for Disease Control and Prevention reported (Infect. Control Hosp. Epidemiol. 2007;28:406-11).

Risk factors associated with the MRSA infections were length of stay, circumcision in the nursery, and receipt of lidocaine injections used to anesthetize for the circumcision procedure. Inspection revealed uncovered circumcision equipment, multiple-dose lidocaine vials, and inadequate hand hygiene practices.

Nineteen cases of MRSA infection were reported in neonates born at Beth Israel Deaconess Medical Center in Boston. Of the 19 infants who have become ill with the drug-resistant staphylococcal infection, 15 have been boys, the Boston Public Health Commission reported. Violations of standard infection control practices related to circumcision and postprocedure care were identified as contributing factors.

A literature review of 10 articles reporting on staphylococcal colonization and infection in the newborn period revealed that male infants have a greater risk than do female infants, and that the male to female ratio is even higher in studies where most of the boys are circumcised as infants (Clin. Pediatr. 2007;46:356-8).

But the answer to the neonatal staphylococcal problem is not to stop circumcising babies. Policies and attitudes toward circumcision are currently being revisited. After a decade or so in which a large body of evidence indicating the procedure reduces the risk for the development of a variety of sexually transmitted diseases was largely ignored, the American Academy of Pediatrics is reviewing its policy on the medical benefits of the procedure.

What's needed is better attention to surgical technique and hygiene during circumcision procedures, along with the use of single-dose lidocaine vials.

For newborns who do develop pustular disease in the diaper area, lower abdomen, or any other area, the approach to management varies considerably. Some infants are hospitalized and treated systemically while others are managed with local or topical therapy. An individualized approach would appear necessary as the spectrum of clinical disease is broad. First, the child should be evaluated for other possible etiologies.

If staphylococcal disease is suspected, the presence or absence of systemic signs, abscess, or local cellulitis will help determine whether systemic therapy is needed or if initial local management is appropriate. In all cases, close follow-up is needed to ensure that resolution occurs.