Injection Of Benzathine Penicillin Research Articles

Acute paraplegia and pulmonary edema after benzathine penicillin injection

Accidental intra-arterial injection is a potentially devastating complication of the intragluteal injection of benzathine penicillin. A 35-year-old woman developed after intramuscular injection of benzathine penicillin G acute paraplegia and noncardiogenic pulmonary edema. Noninvasive positive pressure ventilation was initiated with furosemide and corticosteroids. A magnetic resonance imaging scan showed findings consistent with syringomyelia and spinal cord ischemia at T9 through T10. Vascular injury may be the result of microemboli of the injected crystals of the penicillin salts. The mechanism of noncardiogenic pulmonary edema is perhaps an immunogically mediated one. At 2-year follow-up, she had no improvement in neurologic status. The deficit is considered permanent.

Nicolau syndrome following intramuscular benzathine penicillin

Nicolau syndrome (NS) is a rare complication of an intramuscular injection characterized by severe pain, skin discoloration, and varying levels of tissue necrosis. The case outcomes vary from atrophic ulcers and severe pain to sepsis and limb amputation. We describe a case of a seven-year-old boy with diagnosis of NS after intramuscular benzathine penicillin injection to the ventrolateral aspect of the left thigh. Characteristic violaceous discoloration of skin and immediate injection site pain identified it as a case of NS. The case was complicated by rapid progression of compartment syndrome of the lower limb, proceeding to acute renal failure and death. Associated compartment syndrome can be postulated as a poor prognostic factor for NS.

Tertiary syphilis

Case 1 A 42‐year‐old married man reported heterosexual behavior with multiple partners, chronic alcoholism, and a previous history of urethritis. He presented with a 1‐year history of two asymptomatic, erythematous to violaceous, annular or polycyclic plaques, involving the anterior aspect of the left thigh. The lesions had raised, well‐defined, infiltrated borders, with irregular crusted ulcers at the periphery, and there was central healing with atrophy (Fig. 1). Histologic examination of a skin biopsy specimen showed lymphocytes and plasma cells infiltrating the superficial and deep dermis, and epithelioid granulomas. Warthin–Starry stain for spirochetes was negative. Venereal Disease Research Laboratory (VDRL) test was reactive (1 : 64) and Treponema pallidum hemagglutination assay (TPHA) was positive. Tests for hepatitis B, hepatitis C, human immunodeficiency virus‐1 (HIV‐1), and HIV‐2 were negative. Neurologic examination revealed changes attributable to chronic alcoholism. VDRL test and TPHA of cerebrospinal fluid were negative. Echocardiogram showed moderate dilatation of the ascending aorta, thickening of the aortic valves, and moderate aortic insufficiency. The patient received 2.4 million units of benzathine penicillin G, intramuscularly, once per week for three consecutive weeks, with rapid resolution of the lesions. His wife had a nonreactive VDRL test and positive TPHA, and was treated with the same regimen.Erythematous to violaceous plaque, with crusted and ulcerated border, on the left thighimageCase 2 A 32‐year‐old married woman of rural background and residence presented with a 1‐year history of occasionally pruritic, papulonodular lesions, involving the presternal (Fig. 2) and left eyebrow (Fig. 3) regions, papules in a polycyclic configuration, and clusters of erythematous, infiltrated nodules, some of which showed ulceration with a surface crust. There was central atrophy and noncontractile scarring. Her husband had been treated for primary syphilis approximately 5 years earlier with benzathine penicillin G; however, the wife was not notified and therefore was not treated. Histologic examination of a presternal lesion revealed erosion and acanthosis with irregular papillomatosis of the epidermis, a dense superficial dermal infiltrate of lymphocytes, plasma cells, and epithelioid cells, and granulomas with multinucleated giant cells. Warthin–Starry stain was negative. VDRL test was reactive (1 : 128) and TPHA was positive. Serology for hepatitis B and C and for HIV‐1 and HIV‐2 was negative. VDRL and TPHA analyses of the cerebrospinal fluid were negative. The patient was treated with 2.4 million units of benzathine penicillin G, intramuscularly, once per week for 3 weeks, with rapid resolution of the lesions. One year after treatment, there was slight central, noncontractile atrophy and peripheral hyperpigmentation (Fig. 4).Clustered, infiltrated nodules, with crusted surfaces and central atrophic scarring, in the presternal regionimageInfiltrated nodules with crusted surfaces on the left eyebrowimagePresternal lesions, 1 year after treatmentimageCase 3 Accompanied by a social worker, this single, mentally retarded, indigent 42‐year‐old man presented with a greater than 1‐year history of two fetid, erythematous to violaceous, exudative plaques with ulcerated bases and circinate, ulcerated borders, involving the inner aspects of both thighs (Fig. 5). Histologic examination showed marked pseudoepitheliomatous hyperplasia of the epidermis and marked inflammation of the papillary and reticular dermis, mainly with plasma cells (Fig. 6). Warthin–Starry stain was negative. VDRL test was reactive (1 : 8) and TPHA was positive. Serologic tests for hepatitis B and C and for HIV‐1 and HIV‐2 were negative. Neurologic examination revealed profound memory impairment and abnormal balance. Computed tomography scan of the head and evaluation of the cerebrospinal fluid were unremarkable. The patient was treated with three intramuscular injections of benzathine penicillin G, 2.4 million units, over three consecutive weeks. The lesions responded rapidly to treatment, with evolution to peripheral hyperpigmentation and central, noncontractile atrophy.Ulcerated plaques involving the inner aspect of both thighsimageInflammatory infiltrate with predominance of plasma cells (hematoxylin and eosin, ×1000)image

Therapy for Lyme arthritis: Strategies for the treatment of antibiotic‐refractory arthritis

Lyme arthritis, caused by the tick-borne spirochete Borrelia burgdorferi (1), typically causes intermittent or persistent arthritis in a few large joints, especially the knee, for several years (2). Treatment recommendations have changed over time. In the early 1980s, 3 intramuscular injections of benzathine penicillin or a 10-day course of high-dose intravenous (IV) penicillin cured only 35–55% of patients (3). In the late 1980s, treatment with IV ceftriaxone for 2 weeks was effective in 90% of patients (4,5); slightly better results were achieved with 4 weeks of therapy (6), but adverse events occurred more frequently. During the same period of time, a 4-week course of oral doxycycline or amoxicillin was also effective in 90% of patients with Lyme arthritis (7). However, joint swelling in some patients remained unresponsive to oral therapy and re-treatment with a 2-week course of IV ceftriaxone (7). To date, little information is available about therapy for such patients. One non–antibiotic-treated patient had resolution of joint swelling following hydroxychloroquine therapy (8). Sixteen of 20 patients with persistent arthritis despite antibiotic therapy experienced resolution after arthroscopic synovectomy (9). In 2000, an expert panel from the Infectious Diseases Society of America (IDSA) presented guidelines for the treatment of Lyme disease (10). The panel recommended initial treatment with oral doxycycline or amoxicillin for 4 weeks for patients with Lyme arthritis and no concomitant neurologic abnormalities. Results of a cost–benefit analysis suggested that such therapy is as effective as IV therapy, is safer than IV therapy, and is considerably less expensive (11). For patients in whom arthritis is persistent despite receiving 4 weeks of oral antibiotic therapy, the panel recommended re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of IV ceftriaxone. However, in a small percentage of patients, proliferative synovitis (12,13) persists for months to several years, even after 2 months of treatment with oral antibiotics, 1 month of treatment with IV antibiotics, or both, which we have termed antibiotic-refractory (or slowly resolving) Lyme arthritis.

NICOLAU SYNDROME AFTER INTRAMUSCULAR BENZATHINE PENICILLIN TREATMENT

Nicolau syndrome (livedoid dermatitis) is a very rare complication of intramuscular injections and manifests as excruciating pain immediately after injection. We describe a 3-year-old boy with diagnosis of Nicolau syndrome after intramuscular benzathine penicillin injection to the midanterior part of the left thigh. He was treated with hyberbaric oxygen and pentoxyphilline in addition to supportive treatment and recovered with no sequelae.

Acute Pharyngitis as Challenge for Primary Prevention of Rheumatic Fever at a Rural Community in Gharbia Governorate

It is known that streptococcal infections of the pharynx are the precipitating cause of rheumatic fever. The aim of the present study was to determine some preventable challenges in dealing with acute pharyngitis at a rural community in Gharbia Governorate. This study was conducted at Kafr Hegazy Village, during a period of four months from October 2004 up to the end of January 2005. All primary and preparatory schools of Kafr Hegazy Village were surveyed for children taking long acting penicillin as a preventive measure for rheumatic fever. Sociodemographic characteristics, history of attacks of acute pharyngitis, investigations performed for diagnosis, source of medical care, and type and duration of medications used for treatment were obtained from parents by direct interview using structured questionnaire sheet. All related investigations were reviewed. The results revealed that: In all primary and preparatory schools of Kafr Hegazy Village, 173 children were taking long acting penicillin as a prophylactic measure for rheumatic fever. Of them, 95.4% had past history of acute pharyngitis and 61.9% of them had their first attacks below 6 years and suffered from more than 6 years and suffered from more than 6 attacks per year. There was no statistically significant difference between mother’s education [ꭓ2=7.194] and source of medical care [ꭓ2=5.838] on one hand and frequency of attacks of acute pharyngitis on the other. Governmental health services [53.3%], mainly school health insurance and primary health care unit were the main sources of medical care. The study showed that 58.2% of studied children were not asked for any investigations and only 1.2% of them were asked for throat culture. Also, the study revealed that the majority [84.2%] of rural mothers were seeking medical care for treating acute pharyngitis which was not significantly affected by their education [ꭓ2=1.309]. According to the finding of the study, oral antibiotic therapy was the commonly prescribed, [42.4%], but it was used for 3.9±1.6 days. On other hand, injection therapy [30.3%] was used commonly for 2.4±0.7 days. There was no statistically significant effect of mother’s education or source of medical care on duration of treatment. The following was recommended: Special health education program for mothers to minimize throat infections and rheumatic fever and stress on the necessity of 10-day course of oral treatment, orientation and on job training courses for physicians especially those of the school health insurance, primary health care units, and private ones. Strategies for diagnosis and treatment of acute pharyngitis should be directed at identifying those patients who have group A ẞeta hemolytic streptococcal infections by using throat culture [especially for children under 6 years] and implementation of a single injection of benzathine penicillin G as recommended regimen for both treatment of acute pharyngitis and primary prevention of rheumatic fever.

Rhumatisme articulaire aigu chez l'enfant

Acute rheumatic fever (ARF) is a systemic illness that may occur following group A beta haemolytic streptococcal pharyngitis in children. As indicated by laboratory and epidemiological evidences, ARF may result from an autoimmune response; however, the exact pathogenesis remains unclear. ARF is a major problem in countries with limited resources. It affects the cardiac valves and muscle, joints, skin and central nervous system. The treatment consists of anti-inflammatory drugs. Preventive and prophylactic therapy is indicated to prevent further valve damage. Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis: an injection of benzathine Penicillin G every 3 or 4 weeks.

Colchicine and benzathine penicillin in the treatment of Behcet disease: A case comparative study

Behçet disease is a chronic relapsing disease characterized by multiple signs and symptoms such as recurrent orogenital ulceration, eye involvement, skin manifestations, and other systemic involvement. Multiple therapeutic modalities have been used to treat Behçet disease. These agents act through different mechanisms and are associated with a variety of side effects. We performed a case-comparative study to evaluate efficacy of combined colchicine and benzathine penicillin in the treatment and prophylaxis of Behçet disease. Sixty-six patients who fulfilled the international study group criteria for diagnosis of Behçet disease were included. The patients were divided into three groups: group 1 (20 patients) received 1.2 Mu benzathine penicillin injection monthly; group 2 (21 patients) received two tablets of colchicine daily (each tablet contained 0.5 mg); and group 3 (25 patients) received both 1.2 Mu benzathine penicillin injection monthly and two tablets of colchicine daily. Each patient was followed up monthly for 5 months, 4 months on treatment and 1 additional month followup. The clinical manifestation index (CMI), the numerical sum of the clinical features, was calculated for each patient initially and then monthly. Pathergy test was performed for each patient monthly. The CMI was reduced by colchicine and benzathine penicillin treatment, and the reduction was highly significant. The reduction in the CMI remains satisfactory and good for 1 month after stopping the treatment. When each colchicine and benzathine Penicillin are used alone the index is also reduced significantly, but this reduction is much less than when both drugs are used together and there is also rapid and earlier relapse. Based on our findings, the combination of colchicine and benzathine penicillin appears to be of greater efficacy in the treatment of Behçet disease than the use of either drug alone.

Invasive pneumococcal disease in homozygous sickle cell disease: Jamaican experience 1973-1997

Objectives: To examine the clinical features and epidemiology of invasive pneumococcal disease in homozygous sickle cell (SS) disease and the efficacy of pneumococcal prophylaxis. Study design: A retrospective study of 80 episodes in 68 patients in the Jamaican Sickle Cell Clinic in a 25-year period (1973-1997). Results: Clinical features included a history of fever (94%), vomiting (70%), an ill appearance (80%), fever (89%), abnormal chest signs (43%), and meningismus (39%). There were 14 deaths—13 among 68 initial episodes (6 of which were deaths on arrival) and one death during a recurrence. Thirteen episodes occurred in patients who should have been receiving antibiotic prophylaxis. Ten were due to failure to adhere to protocols, and 3 occurred during prophylaxis; one patient was receiving oral erythromycin, and two had received injections of benzathine penicillin 4 and 24 days before the episode. All but one of the pneumococcal isolates were susceptible to penicillin. The 32 patients who received pneumococcal vaccine had more mild clinical courses as indicated by a greater chance of being treated as outpatients or surviving after admission (Mann-Whitney U test, P =.03). Conclusions: Penicillin remains the mainstay of prophylaxis, although breakthroughs occur and will become more common with the increasing frequency of penicillin-resistant organisms. Pneumococcal immunization appears to ameliorate the course of invasive disease. (J Pediatr 2001; 138:65-70)

Anaphylaxis to Benzathine Penicillin G

We report on two military trainees who experienced anaphylaxis following an injection of benzathine penicillin G (BPG). A total of 9203 trainees received a prophylactic dose of BPG over a 6-month period for an incidence rate of 0.022%. One of the trainees experienced biphasic or recurrent anaphylaxis. We discuss the issue of management of anaphylaxis following an injection of a depot form of penicillin especially with regards to biphasic anaphylaxis. (Pediatr Asthma Allergy Immunol 2000;14[4]:329–332.)

Rheumatic fever

There have been numerous reports stating that treatment of acute rheumatic fever with either aspirin or corticosteroids does not alter the long-term outcome of rheumatic heart disease. Yet, it should be emphasized that most of these studies were carried out with the first generic corticosteroids before the advent of the more active and more potent corticosteroid agents. In spite of this caveat, there is no question that all the clinical and laboratory parameters of inflammation (erythrocyte sedimentation rate, C-reactive protein) return to normal much more rapidly with corticosteroids than with aspirin alone. It is therefore our belief that steroids should be used when clinical and laboratory evidence of carditis exists, and aspirin should be reserved for cases of acute rheumatic arthritis with no evidence of carditis. The incidence of long-term valvular disease in active carditis may be decreased with steroid therapy. For example, the number of valve replacements differs markedly in centers that do use steroids and in those that do not. In Capetown, South Africa, where steroids are routinely used for carditis, valve replacement is quite rare. In contrast, in Johannesburg, where steroids are rarely used, the rate of valve replacement is quite high. The racial backgrounds of both groups of patients are similar, thus eliminating the question of racial differences. Concerning secondary prophylaxis, there is also controversy concerning the best second-line therapy. It is now well known that monthly intramuscular injections of benzathine penicillin are really effective for only 20 days. Thus, there is a window in which penicillin coverage is not adequate. To circumvent this problem, some investigators give benzathine penicillin every 3 weeks. These injections are quite painful, however, and it has been our "rule" that compliance with this treatment is inversely proportional to the ratio of the size of the child to the mother. In our own experience over 30 years with the follow-up of more than 300 patients with acute rheumatic fever, careful discussion of the consequences of missing oral doses has been adequate to insure proper compliance. An analysis of our patients on oral penicillin prophylaxis compared with other groups using benzathine penicillin revealed that there was very little difference in recurrence rate.

Benzathine penicillin for unilateral lobar or segmental infiltrates presumptively caused by Streptococcus pneumoniae in children 2-12 years old

A randomized controlled study was carried out to assess the efficacy of a single dose of benzathine penicillin for treating children 2-12 years old with presumed S. pneumoniae pneumonia. One-hundred-and-seventy-six children screened at self-referral pediatric emergency services in Belo Horizonte, Brazil, were randomized to only one injection of benzathine penicillin (n = 93, case-group) or a 7-day procaine penicillin regimen (n = 83, control-group), upon diagnosis of pneumococcal pneumonia based on clinical and radiological characteristics. Follow-up was carried out on the second day after treatment and around the 7th and/or 14th day after treatment allocation. No statistical significant difference was found for sociodemographic, clinical, laboratory or radiographic characteristics among the two groups. Evident or total radiographic clearing was demonstrated for 92.3 and 95.1 per cent of the benzathine penicillin and procaine penicillin groups, respectively (P = 0.54). Benzathine penicillin may be considered an alternative to classic regimens for treating pneumonia due to sensitive strains of S. pneumoniae among children 2-12 years old. Other benefits are its lower cost, better compliance and low rates of adverse reactions.

Apparent failure of one injection of benzathine penicillin G for syphilis during pregnancy in human immunodeficiency virus-seronegative African women.

Syphilis remains a major cause of premature birth, fetal and perinatal death, and congenital syphilis in South Africa, despite systematic antenatal screening by rapid plasma reagin and treatment with 2.4 million U of benzathine penicillin G. To determine whether one injection of 2.4 million of U of benzathine penicillin G, as recommended by the 1993 Centers for Disease Control and Prevention guidelines, is sufficient treatment for early syphilis during pregnancy. Outcome of pregnancy was prospectively analyzed after zero to three weekly intramuscular injections of benzathine penicillin G in 180 of 212 human immunodeficiency virus-seronegative black urban women with syphilis in Pretoria, South Africa. One hundred eight women receiving two or three weekly intra-gluteal injections of benzathine penicillin G had a favorable pregnancy outcome. However, after only one injection, lower birth weight, increased immaturity, prematurity, and total preterm birth rate resulted. Total pregnancy loss and perinatal mortality were also increased. After exclusion of patients treated with oral penicillin derivatives and adjustment for the estimated duration of treponemicidal levels at 3 weeks after injection, the perinatal outcome was reanalyzed. Treponemicidal coverage of 3 weeks or less resulted in decreased birth weight (2,748 vs. 3,130 g, P = 0.004) compared with treponemicidal coverage lasting longer than 3 weeks. In addition, the relative risks for prematurity (relative risk [RR], 8.5; 95% confidence interval [CI95], 2.5-28), perinatal mortality (RR, 20.5; CI95, 2.3-184), and congenital syphilis (RR 2.0; CI95-0.6-6.8) were increased when coverage was less then 3 weeks. These results were comparable to those obtained when no treatment was given. Most of the incompletely treated women delivered at less than 4 weeks after they received their injection. These also had the worst neonatal outcome. Impaired outcome due to short treatment clustered in early attenders of prenatal care (before the 28th week of gestation) and when the initial rapid plasma reagin titer was higher than 16. Although numbers were small for a firm conclusion, incompletely treated and untreated women who had taken intercurrent oral ampicillin had an improved birth weight, lower prematurity rate, and lower fetal rate. One intramuscular injection of 2.4 million U benzathine penicillin G or treponemicidal concentrations lasting 3 weeks or less is not sufficient therapy for pregnant women with syphilis. Although fetal outcome is clearly improved at birth with more than one injection, without follow-up of the neonates, complete cure cannot be predicted from these data. To obtain treponemicidal activity for longer than 3 weeks, the authors recommend administration of two injections of 2.4 million U benzathine penicillin at least 1 week apart, if possible at 4 weeks or more before delivery. This therapy is especially important for patients who attend prenatal care before 28 weeks of pregnancy or when the rapid plasma reagin titer is higher than 16.

Semicircular lipoatrophy after intragluteal injection of benzathine penicillin

A 3-year-old girl had localized lipoatrophy after an intragluteal injection of benzathine penicillin G. No associated abnormalities were found. (J P EDIATR 1996;129: 166-7)

Group A Streptococcal Tonsillopharyngitis: Cost-Effective Diagnosis and Treatment

See related editorial, "Acute Pharyngitis: The Case for Empiric Antimicrobial Therapy"Most patients who seek medical attention for sore throat are concerned about streptococcal tonsillopharyngitis, but fewer than 10% of adults and 30% of children actually have a streptococcal infection. Group A β-hemolytic streptococci (GAS) are most often responsible for bacterial tonsillopharyngitis, although Neisseria gonorrhea, Arcanobacterium haemolyticum (formerly Corynebacterium haemolyticum), Chlamydia pneumoniae (TWAR agent), and Mycoplasma pneumoniae have also been suggested as possible, infrequent, sporadic pathogens. Viruses or idiopathic causes account for the remainder of sore throat complaints. Reliance on clinical impression to diagnose GAS tonsillopharyngitis is problematic; an overestimation of 80% to 95% by experienced clinicians typically occurs for adult patients. Overtreatment promotes bacterial resistance, disturbs natural microbial ecology, and may produce unnecessary side effects. Existing data suggest that rapid GAS antigen testing as an aid to clinical diagnosis can be very useful. When used appropriately, it is sensitive (79% to 88%) in detecting GAS-infected patients and is specific (90% to 96%) and cost-effective. Penicillin has been the treatment of choice for GAS tonsillopharyngitis since the 1950s; 10 days of treatment are necessary for bacterial eradication. A single IM injection of benzathine penicillin is effective and obviates compliance issues. Until the early 1970s, the bacteriologic failure rate for the treatment of GAS tonsillopharyngitis ranged from 2% to 10% and was attributed to chronic GAS carriers. Since the late 1970s, the penicillin failure rate has frequently exceeded 20% in published reports. Explanations for recurrent GAS tonsillopharyngitis include poor patient compliance; reacquisition from a family member or peer, copathogenic colonization by Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis, anaerobes that inactivate penicillin with β-lactamase, or all these organisms; suppression of natural immune response by too-early administration of antibiotics; GAS tolerance to penicillin; antibiotic eradication of normal pharyngeal flora that normally act as natural host defenses; and establishment of a true carrier state. When therapy fails, milder symptoms may occur during the relapse. Several antimicrobials have demonstrated superior efficacy compared with penicillin in eradicating GAS and are administered less frequently to enhance patient compliance. In previously untreated GAS throat infections, cephalosporins produce a 5% to 22% higher bacteriologic cure rate; after a penicillin treatment failure, these differences are greater. Amoxicillin/clavulanate and the extended-spectrum macrolides clarithromycin and azithromycin may also produce enhanced bacteriologic eradication in comparison to penicillin. Future research is needed in the development of more sensitive rapid-detection assays for GAS and other possible pathogens in tonsillopharyngitis and of shorter-course regimens of therapy and in determining the necessity and benefit of treatment of non-GAS tonsillopharyngeal isolates.[Pichichero ME: Group A streptococcal tonsillopharyngitis: Cost-effective diagnosis and treatment. Ann Emerg Med March 1995;25:390-403.]

İntramüsküler Benzatin Penisilin Enjeksiyonuna Bağlı Bir Ölüm Olgusu

A 2 5 year old girl who died due to disseminated thromboembolism following I M injection of benzathine penicillin which entered arterial circulation accidentally is reported The complications and risk factor of intramuscular injections are discussed and the literature is reviewed Key words: Benzathine Penicillin Complication Intra Arterial Injection

Is Standard Practice 'Standard' In Community Pediatrics?

Sir .—After reading the editorial by Fulginiti 1 and the articles by Schunk et al 2 and Caravati et al 3 in the May issue of AJDC regarding pediatric coin ingestion, I telephoned 11 fellow pediatricians to learn how they would respond to an asymptomatic child who had swallowed a coin. I also decided to ask whether they would prescribe oral antibiotic therapy or administer an injection of benzathine penicillin to a nonallergic child weighing more than 18 kg whose throat culture results or rapid-strept test results were positive for streptococcal infection. Atlanta, Ga, is a medical school city with two tertiary care–level children's hospitals that strongly encourage continuing medical education for their physicians. All the pediatricians I questioned are members of the active staffs of at least one of the children's hospitals. My questions were the same to each pediatrician: If you have a totally asymptomatic child in no

Pharmacokinetics of benzathine penicillin G: Serum levels during the 28 days after intramuscular injection of 1,200,000 units

Because of published data suggesting the inadequacy of once-every-4-weeks intramuscular injections of benzathine penicillin G for secondary rheumatic fever prevention, serum penicillin levels were determined at 1, 3, 10, 21, and 28 days after administration of 1,200,000 units of this repository penicillin. A total of 193 samples were studied. Mean serum penicillin levels remained greater than or equal to 0.02 micrograms/ml for 21 days, but by 28 days only 44% of the serum samples had detectable levels of penicillin and only 36% had levels greater than or equal to 0.02 micrograms/ml. Patients weighing more than 45 kg had significantly lower serum penicillin levels than did those who weighed less. There were similar correlations with body surface area and with age. These data indicate that a significant percentage of patients receiving benzathine penicillin G prophylaxis for prevention of recurrent attacks of rheumatic fever are not protected during the fourth week. More frequent administration of benzathine penicillin G should be considered in instances of high risk of recurrence of rheumatic fever.

CARE OF INFANTS WITH DISEASE: THE ULTIMATE OBJECTIVE OF NEWBORN SCREENING

We conclude that newborn screening with a comprehensive follow-up program, emphasizing parental education and the use of penicillin prophylaxis, is effective in reducing morbidity and mortality from pneumococcal infections in infants with sickle cell disease. One of the 159 infants followed-up during 1981 to 1986 died as a result of overwhelming sepsis. This compares with an anticipated mortality rate at that time of 10%. Penicillin prophylaxis should be started at 3 months of age in infants with Hb SS and should also be given to infants with hemoglobin SC and S- β-thalassemia. The duration for which prophylaxis must be given is not known, but it should be continued at least through the age of 5 years. Monthly injections of benzathine penicillin is an inadequate regimen; we recommend that, if penicillin is to be administered by the intramuscular route, it should be given every 3 weeks and supplemented in the last week with oral penicillin. However, we now emphasize that the daily oral administration of penicillin is the preferred method of administration for prophylaxis. Pneumococcal vaccine continues to be given at 2 years of age, with a booster dose recommended at 4 to 5 years of age. H influenzae vaccine conjugates are immunogenic when given at 18 months, and newer vaccines may soon be available that can be given much earlier. Finally, and most important, the program must be structured in such a way as to thoroughly involve the parents in assuming responsibility for their child's continued health and well being.

Aetiology of genital ulceration in the Gambia.

The aetiology of genital ulceration was studied in 104 unselected patients (94 men, 10 women) attending a sexually transmitted disease (STD) clinic in the Gambia. Chancroid was diagnosed in 54 (52%), syphilis in 23 (22%), lymphogranuloma venereum (LGV) in seven (7%), and herpes in six (6%). In 28 (27%) patients no diagnosis was reached. Ten (10%) patients were found to have both chancroid and syphilis, three (3%) had both LGV and syphilis, and one (1%) had both herpes and syphilis. Trimethoprim 160 mg and sulphamethoxazole 800 mg twice daily for one week was found to be effective in the treatment of chancroid. This regimen with a single intramuscular injection of benzathine penicillin 2.4 MIU is recommended for the treatment of genital ulcers in Gambian health centres without laboratory facilities.