Discontinuing penicillin prophylaxis in children with sickle cell anemia. Prophylactic Penicillin Study II.
OBJECTIVE
To evaluate the consequences of discontinuing penicillin prophylaxis at 5 years of age in children with sickle cell anemia who had received prophylactic penicillin for much of their lives.


METHODS
Randomized, double-blind, placebo-controlled trial.


METHODS
Eighteen teaching hospitals throughout the United States.


METHODS
Children with sickle cell anemia (hemoglobin SS or hemoglobin S beta 0-thalassemia) who had received prophylactic penicillin therapy for at least 2 years immediately before their fifth birthday and had received the 23-valent pneumococcal vaccine between 2 and 3 years of age and again at the time of randomization. Of 599 potential candidates, 400 were randomly selected and followed for an average of 3.2 years.


METHODS
After randomization, patients received the study medication twice daily--either penicillin V potassium, 250 mg, or an identical placebo tablet. Patients were either seen in the clinic or contacted every 3 months thereafter for an interval history and dispensing of the study drug. A physical examination was scheduled every 6 months.


METHODS
The primary end point was a comparison of the incidence of bacteremia or meningitis caused by Streptococcus pneumoniae in children continuing penicillin prophylaxis versus those receiving the placebo.


RESULTS
Six children had a systemic infection caused by S. pneumoniae, four in the placebo group (2.0%; 95% confidence interval 0.5%, 5.0%) and two in the continued penicillin prophylaxis group (1.0%; 95% confidence interval 0.1%, 3.6%) with a relative risk of 0.5 (95% confidence interval 0.1, 2.7). All invasive isolates were either serotype 6(A or B) or serotype 23F. Four of the isolates were penicillin susceptible, and two (one from each treatment group) were penicillin and multiply antibiotic resistant. Adverse effects of the study drug were reported for three patients (nausea, vomiting, or both), one of whom was in the placebo group.


CONCLUSIONS
Children with sickle cell anemia who have not had a prior severe pneumococcal infection or a splenectomy and are receiving comprehensive care may safely stop prophylactic penicillin therapy at 5 years of age. Parents must be aggressively counseled to seek medical attention for all febrile events in children with sickle cell anemia.
D000755:Anemia, Sickle Cell / Q000150:complications / Q000628:therapy*; D016470:Bacteremia / Q000209:etiology / Q000517:prevention & control; D001428:Bacterial Vaccines / Q000276:immunology; D002675:Child, Preschool; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D008297:Male; D008586:Meningitis, Pneumococcal / Q000209:etiology / Q000517:prevention & control; D010406:Penicillins / Q000009:adverse effects / Q000627:therapeutic use*; D011008:Pneumococcal Infections / Q000209:etiology / Q000517:prevention & control; D013296:Streptococcus pneumoniae / Q000276:immunology; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
D001428:Bacterial Vaccines; D010406:Penicillins