Circumcision is the surgical removal of the skin covering the head of the penis. It is a relatively safe procedure. Although complications of neonatal circumcision are rare, sepsis, genital mutilation, gangrenous penis, profuse bleeding, permanent disability from the complete or partial amputation of the glans or shaft, the formation of a skin bridge between the penile shaft and the glans, urinary retention, meatal ulcers, meatal stenosis, fistulae, loss of penile sensitivity, dehydration (may result in renal failure), sexual dysfunction and edema of the glans penis have been reported [6]. Circumcision when performed outside the hospital setting by an untrained circumciser is associated with an increase in fatal complications. Therefore, it has been suggested that infectious complications can be reduced with trained and competent practitioners performing the procedure using sterile techniques [7].

In the reported case, the neonate had an early onset Klebsiella pneumoniae infection presented as scrotal swelling followed by right buttock swelling and right ankle abscess on the 8^th day of his life. Neonate had no previous history of infection, or direct contact with an infected person, primary immunodeficiency syndrome was also ruled out. All these findings pointed toward the complication of circumcision. In our review, complications due to HSV, syphilis, TB, staphylococcus aureus, streptococcus pneumoniae, and proteus have been found [6-8]. Although fatal complications of circumcision are rare, they should not be excluded. These are some references to the fatal complications of circumcision [9-12]. Most of the cases were presented as sepsis, and multiple and recurrent swellings, as did in our patient. Interestingly, in none of the patients, Klebsiella pneumoniae was isolated. Klebsiella pneumoniae is a gram-negative nosocomial pathogen, transmitted in a hospital or healthcare setting via direct contact (commonly, from patient to patient via the contaminated hands of healthcare personnel) or less commonly via a contaminated environment. This suggested that the route of transmission in our patient is via a contaminated source. Immunocompromised patients and children are at increased risk of Klebsiella Pneumoniae infection.

The clinical manual by the World Health Organization (WHO), discusses male circumcision under local anesthesia and HIV prevention services for adolescent boys and men [13]. Information on basic steps of circumcision such as how to put on and take off surgical gloves, preparing the skin of the genital area of the patient three times, pre-procedure screening, optimal surgical technique based on the level of expertise and patient circumstances, recognizing and responding to adverse events, etc. provides a basis for safe circumcision practice which can be adopted as a Standard of Procedure (SOPs), in various settings providing the service. Evidence based educational sessions are more frequently needed with strict adherence to the SOPs to prevent complications from arising.