Influence of penicillin prophylaxis on antimicrobial resistance in nasopharyngeal S. pneumoniae among children with sickle cell anemia. The Ancillary Nasopharyngeal Culture Study of Prophylactic Penicillin Study II.

PURPOSE: To evaluate the consequences of prolonged prophylactic penicillin use on the rates of nasopharyngeal colonization with Streptococcus pneumoniae and the prevalence of resistant pneumococcal strains in children with sickle cell anemia. METHODS: Nasopharyngeal specimens were obtained from children with sickle cell anemia (Hb SS or Hb S beta degrees thalassemia) at 10 teaching hospitals throughout the United States. These patients were participating in a prospective, randomized, placebo-controlled trial in which they were prescribed prophylactic penicillin before their fifth birthday and were randomized to prophylactic penicillin or placebo after their fifth birthday (PROPS II). The specimens were cultured for S. pneumoniae, and isolates were analyzed for antimicrobial susceptibility to nine commonly prescribed antimicrobial agents. RESULTS: Of the 226 patients observed, an average of 8.4 specimens were collected per patient. From 1,896 individual culture specimens, 5.5% of the specimens were positive for S. pneumoniae; 27% of patients had at least one positive culture. Nine percent of the study patients had at least one isolate of penicillin intermediate or resistant pneumococci. There was no significant difference in the percent of positive cultures for S. pneumoniae in those patients given penicillin prophylaxis after 5 years of age (4.1%) compared with those patients given placebo after 5 years of age (6.4%). Likewise, there was no significant difference (p = 0.298) in the percent of patients with at least one positive culture for S. pneumoniae in the group given prophylactic penicillin after 5 years of age (21.8%) compared with the group given placebo after 5 years of age (28.3%). There was no difference between the penicillin and placebo groups in the proportion of patients with penicillin intermediate or resistant pneumococci, but there was a trend toward increased carriage of multiply drug-resistant pneumococci in children > 5 years of age receiving prophylactic penicillin compared to children > 5 years of age receiving placebo. The increased colonization rate with multiply drug-resistant organisms of children > 5 years of age receiving penicillin prophylaxis is not statistically significant. CONCLUSIONS: The potential for continued penicillin prophylaxis to contribute to the development of multiply resistant pneumococci should be considered before continuing penicillin prophylaxis in children with sickle cell anemia who are older than 5 years of age. Added to the published data from PROPS II, which demonstrated no apparent advantage to continue prophylaxis, the data support the conclusion that, for children with no history of invasive pneumococcal disease, consideration should be given to discontinue prophylactic penicillin after their fifth birthday.

Life-threatening cervico-mediastinal haematoma after carotid sinus massage.

Retropharyngeal and cervico-mediastinal haematomas are rare but potentially fatal entities. The potential for airway compression necessitates rapid assessment and treatment. A cervico-mediastinal haematoma following carotid sinus massage which required cervical drainage is presented. This is a life-threatening event demanding a high index of suspicion. A review of the literature and indications for treatment are discussed.

Judgments of educators and child-care personnel about appropriate treatment for mentally retarded or normal, overactive or withdrawn, boys.

Special educators and child-care personnel ranked the appropriateness of various psychological treatments for a boy described either as mentally retarded or of normal intelligence and whose behavior was described either as withdrawn or overactive. The predicted IQ level by behavior interaction was found only for drug treatment, which was ranked as relatively more appropriate for the retarded overactive child (p less than .05). Drug treatment and behavior modification were perceived as more appropriate for the overactive child (p less than .01, .05). Play therapy, family therapy, and no treatment were deemed more appropriate for the withdrawn child (p less than .05). Educators favored behavior modification and school consultation more than did child-care personnel (p less than .05).