Secondary Prophylaxis Of Rheumatic Fever Research Articles

Adherence rates and risk factors for suboptimal adherence to secondary prophylaxis for rheumatic fever.

AimSecondary prophylaxis with 3–4 weekly benzathine penicillin G injections is necessary to prevent disease morbidity and cardiac mortality in patients with acute rheumatic fever (ARF) and rheumatic heart disease (RHD). This study aimed to determine secondary prophylaxis adherence rates in the Far North Queensland paediatric population and to identify factors contributing to suboptimal adherence.MethodsA retrospective analysis of data recorded in the online RHD register for Queensland, Australia, was performed for a 10‐year study period. The proportion of benzathine penicillin G injections delivered within intervals of ≤28 days and ≤35 days was measured. A multi‐level mixed model logistic regression assessed the influence of age, gender, ethnicity, suburb, Accessibility and Remoteness Index of Australia class, number of people per dwelling, Index of Relative Socio‐economic Advantage and Disadvantage, Index of Education and Occupation, year of inclusion on an ARF/RHD register and individual effect.ResultsThe study included 277 children and analysis of 7374 injections. No children received ≥80% of recommended injections within a 28‐day interval. Four percent received ≥50% of injections within ≤28 days and 46% received ≥50% of injections at an extended interval of ≤35 days. Increasing age was associated with reduced delivery of injections within 35 days. Increasing year of inclusion was associated with improved delivery within 28 days. The random effect of individual patients was significantly associated with adherence.ConclusionsImproved timely delivery of secondary prophylaxis for ARF and RHD is needed as current adherence is very low. Interventions should focus on factors specific to each individual child or family unit.

Mismatches between health service delivery and community expectations in the provision of secondary prophylaxis for rheumatic fever in New Zealand

ObjectiveRheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Māori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non‐adherence. This research explored Māori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. MethodsParticipants were Māori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Māori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. ResultsData collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implicationsSuccessful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service‐delivery models should provide regular prophylaxis in an accessible manner through culturally‐safe, community‐based, age‐appropriate care.

Enablers and barriers to secondary prophylaxis for rheumatic fever among M\u0101ori aged 14\u201321 in New Zealand: a framework method study

BackgroundAcute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21.MethodsThis study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.”ResultsBarriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections.ConclusionThis detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

Preliminary consultation on preferred product characteristics of benzathine penicillin G for secondary prophylaxis of rheumatic fever

Rheumatic fever is caused by an abnormal immune reaction to group A streptococcal infection. Secondary prophylaxis with antibiotics is recommended for people after their initial episode of rheumatic fever to prevent recurrent group A streptococcal infections, recurrences of rheumatic fever and progression to rheumatic heart disease. This secondary prophylaxis must be maintained for at least a decade after the last episode of rheumatic fever. Benzathine penicillin G is the first line antibiotic for secondary prophylaxis, delivered intramuscularly every 2 to 4weeks. However, adherence to recommended secondary prophylaxis regimens is a global challenge. This paper outlines a consultation with global experts in rheumatic heart disease on the characteristics of benzathine penicillin G formulations which could be changed to improve adherence with secondary prophylaxis. Characteristics included dose interval, pain, administration mechanism, cold chain independence and cost. A sample target product profile for reformulated benzathine penicillin G is presented.

Approaches to Improving Adherence to Secondary Prophylaxis for Rheumatic Fever and Rheumatic Heart Disease: A Literature Review with a Global Perspective.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are autoimmune conditions resulting from infection with group A streptococcus. Current management of these conditions includes secondary antibiotic prevention. This comprises regular 3 to 4 weekly long-acting intramuscular benzathine penicillin injections. Secondary antibiotic prevention aims to protect individuals against reinfection with group A streptococcus, thereby preventing recurrent ARF and the risk of further damage to the heart valves. However, utilization of benzathine penicillin can be poor leaving patients at risk of avoidable and progressive heart damage. This review utilizes the Chronic Care Model as a framework to discuss initiatives to enhance the delivery of secondary antibiotic prophylaxis for ARF and RHD. Results from the search strategy utilized revealed that there is limited pertinent published evidence. The evidence that is available suggests that register/recall systems, dedicated health teams for delivery of secondary antibiotic prophylaxis, education about ARF and RHD, linkages with the community (particularly between health services and schools), and strong staff-patient relationships may be important. However, it is difficult to generalize findings from individual studies to other settings and high quality studies are lacking. Although secondary antibiotic prophylaxis is an effective treatment for those with ARF or RHD, the difficulties in implementing effective programs that reduce the burden of ARF and RHD demonstrates the importance of ongoing work in developing and evaluating research translation initiatives.

Infective endocarditis in Ethiopian children: a hospital based review of cases in Addis Ababa.

IntroductionInfective endocarditis is an infection of the endocardial lining of the heart mainly associated with congenital and rheumatic heart disease. Although it is a rare disease in children, it is associated with high morbidity and mortality; death due to infective endocarditis has been reported to be as high as 26% in sub-Saharan Africa.MethodsThis was a retrospective review of routinely collected data from patient records.ResultsA total of 40 children (71% female) with 41 episodes of infective endocarditis admitted to a general paediatric ward in Addis Ababa, Ethiopia between 2008 and 2013. Age ranged from 7 months to 14 years, with a median of 9 years (Inter quartile Range: 7-12 years). Rheumatic and congenital heart diseases were underlying risk factors in 49% and 51% of cases respectively. Congestive heart failure, systemic embolization and death occurred in 66%, 12% and 7.3% respectively. Death was associated with the occurrence of systemic embolization (P-value = 0.03).ConclusionRheumatic heart disease was an important predisposing factor for infective endocarditis in Ethiopian children. Late presentations of cases were evidenced by high proportion of complications such as congestive heart failure. A low rate of clinically evident systemic embolization in this study may be a reflection of the diagnostic challenges. High proportion of prior antibiotic intake might explain the cause of significant BCNE. Preventive measures like primary and secondary prophylaxis of rheumatic fever may decrease the associated morbidity and mortality. Early detection and referral of cases, awareness creation about indiscriminate use of antimicrobials, and proper history taking and documentation of information recommended.

Incidental histological diagnosis of acute rheumatic myocarditis: case report and review of the literature.

Rheumatic fever (RF) remains endemic in many countries and frequently causes heart failure due to severe chronic rheumatic valvular heart disease, which requires surgical treatment. Here, we report on a patient who underwent an elective surgical correction for mitral and aortic valvular heart disease and had a post-operative diagnosis of acute rheumatic carditis. The incidental finding of Aschoff bodies in myocardial biopsies is frequently reported in the nineteenth-century literature, with prevalences as high as 35%, but no clinical or prognostic data on the patients is included. The high frequency of this finding after cardiac surgery in classical reports suggests that these patients were not using secondary prophylaxis for RF. We discuss the clinical diagnosis of acute rheumatic myocarditis in asymptomatic patients and the laboratorial and imaging methods for the diagnosis of acute rheumatic carditis. We also discuss the prognostic implications of this finding and review the related literature.

Allergic reaction to long – term Benzathine penicillin injection for secondary prevention of acute rheumatic fever and recommendations for skin testing

Background Rheumatic Fever (RF) causes 25-40% of all cardio vascular disease in developing countries. Long term benzathine penicillin injection is being used for secondary prophylaxis of RF / RHD. Although allergic reaction to penicillin is rare skin testing is performed routinely before each and every penicillin injection delivery in most of the hospitals in Nepal. Objectives Objectives of this study was to evaluate safety of long term benzathine penicillin injection and establish recommendations for penicillin skin testing. Methods Data from the registers of National RF/RHD prevention and control programme from 32 hospitals of Nepal were collected and analyzed in a retrospective study. Results 65 patients (1.4%) among 77300 injections of benzathine penicillin given to 4712 patients, had allergic reactions. 5 had anaphylaxis, an incidence of 0.1% (0.7/10000 injections), 60 had minor allergy, an incidence of 1.3%. Conclusions Life-threatening allergic reactions are very rare in patients on long-term intramuscular benzathine penicillin for secondary prevention of RF. With these rare complications, regular skin test before each and every benzathine penicillin injection delivery has no significant role. Nevertheless Skin testing is recommended before 1st injection and patients having different batch number and or brand name. DOI: http://dx.doi.org/10.3126/njh.v8i1.8331 Nepalese Heart Journal Vol.8(1) 2011 pp.16-18

Estudo comparativo das avaliações clínica e ecocardiográfica Doppler na evolução das lesões valvares em crianças e adolescentes portadores de febre reumática

Compare clinical and Doppler echocardiographic evaluations in assessing valvular diseases in children and adolescents with rheumatic fever, as well as assess the progression of the disease in light of these assessments. This is a longitudinal study of 258 children and adolescents diagnosed with rheumatic fever according to Jones criteria. The follow-up period ranged from 2-15 years. The presence and quantification of valve diseases were determined by means of clinical and Doppler echocardiographic evaluations performed during the acute and chronic phases. The Kappa statistics method was used to estimate the degree of agreement between clinical and Doppler echocardiographic evaluations. Comparisons between clinical and Doppler echocardiographic findings on the progress of carditis and valvulitis, respectively, were made using chi-square test or Fishers exact test, p< 0.05. Of the 109 patients who underwent Doppler echocardiographic evaluation during the acute phase, 31 did not present clinical evidence of carditis, but the Doppler echocardiograms of 17 (54.8%) of them showed valve lesions (subclinical valvulitis). During the chronic phase, 153 of the 258 patients had normal cardiovascular examination results; however, Doppler echocardiograms showed that 81 of them (52.9%) had valve lesions (subclinical chronic valvular diseases). Involution of the valvular lesions, as shown by Doppler echocardiographic evaluations, was less frequent and occurred in 10 (25.0%) patients with mild valvulitis, in only one (2.5%) patient with moderate valvulitis, and in none of the patients with severe valvulitis. The identification of rheumatic fever valve lesions can be enhanced when clinical evaluations are supplemented by Doppler echocardiographic examinations; also, clinical examinations are not as suitable to detect valvular lesion regression as the echocardiography. The diagnosis of subclinical valvulitis and valvulopathy influences the secondary prophylaxis of rheumatic fever and endocarditis.

Evaluation of DNA damage using the comet assay in children on long-term benzathine penicillin for secondary prophylaxis of rheumatic fever.

Benzathine penicillin is the most widely used antibiotic in the prophylaxis of children with rheumatic fever. The aim of the present study was to evaluate the DNA damage in children receiving one dose of 1.2 million units benzathine penicillin every 4 weeks over a long period to prevent recurrences of rheumatic fever. Thirty-five children with confirmed rheumatic fever under benzathine penicillin prophylaxis were enrolled in the study and 35 healthy children with similar ages and socioeconomic backgrounds served as controls. To detect any DNA damage, the comet assay was performed on circulating lymphocytes from the study subjects. Damaged (limited and extensive migration) cells in children on prophylactic therapy were higher than those in controls (P<0.001). It has been suggested that differences in the comet scores were induced by the administration of benzathine penicillin over a long period of time and further investigations are needed to confirm this toxic effect.

Prophylactic efficiency of 3-weekly benzathine penicillin G in rheumatic fever.

Benzathine penicillin G (BPG) is effective for secondary prophylaxis of rheumatic fever (RF). However, interval between injections a remains a controversial matter. In a study population of 74 patients, following the initial diagnosis of RF, 3-weekly BPG (1.2 million units) regimen was started. During the first three-week period, serum penicillin concentrations were examined on the 7th, 14th and 21st days and throat culture done for group-A b hemolytic streptococcal (GABHS) infection. Ten patients (13.5%) at 21st day of injection had low serum penicillin concentration after the first BPG. GABHS was isolated in 5 patients during this period. Although two of these 5 patients had symptoms of respiratory tract infection, according to laboratory data, the other three were accepted as carriers. All 74 patients were then followed-up for rheumatic recurrence (RR) during long-term period (6 to 60 months, mean 25 +/- 5 months). There was no RR among regular (missing no more than one injection a year) group. We concluded that 3-weekly BPG regimen was satisfactory for secondary prophylaxis in RF, even though serum penicillin level was inadequate during the third week in some of the patients.

Are the Currently Recommended Doses of Benzathine Penicillin G Adequate for Secondary Prophylaxis of Rheumatic Fever?

To review the literature on dose and regimens of intramuscular benzathine penicillin G (BPG) for secondary prophylaxis of recurrent rheumatic fever. For over 40 years BPG has been the gold standard for secondary prophylaxis, usually as a dose of 1,200,000 U (900 mg). Although studies have suggested that BPG injections every 3 weeks are superior to injections every 4 weeks, implementation of an every 3 weeks regimen can be problematic with regards to both patient compliance (adherence) and an increased burden on health resources. Some of the earliest studies of BPG suggested that larger doses resulted in prolongation of detectable penicillin levels. A recent study assessing plasma penicillin levels after BPG doses of 1,200,000 U, 1,800,000 U, and 2,400,000 U suggested there may be benefits in a BPG regimen every 4 weeks with doses higher than the standard 1,200,000 U. Further studies of higher dose BPG regimens seem justified. In addition, further work is needed on quality and storage options for different BPG preparations; location and method of BPG injections; the importance of weight differences between individuals; and ways of improving access to and compliance with BPG regimens.

Evaluation of secondary prophylactic schemes, based on benzathine penicillin G, for rheumatic fever in children

Serum concentrations of penicillin were measured in children with rheumatic fever. The adequacy of the values after administration of 1.2 million units of benzathine penicillin G every 2 or 3 weeks was confirmed; the adequacy of a 4-week regimen was questionable. The administration of 0.6 million units every 3 weeks was found to be inadequate to maintain serum levels high enough for the secondary prophylaxis of rheumatic fever.

Antibodies to penicillin in children receiving long-term secondary prophylaxis for rheumatic fever.

The occurrence of IgE and IgG antibodies to penicillin G and V in children on long-term treatment with penicillin as secondary prophylaxis for rheumatic fever was studied using Phadebas RAST (Pharmacia Diagnostics, Uppsala, Sweden) and ELISA respectively. The duration of the prophylaxis ranged between 1.5 months and 5 years (mean 1.8 years). Of 18 patients who had been given penicillin for more than 1.5 months, two had IgE antibodies and 12 had IgG antibodies to penicillin. Patients with acute rheumatic fever who had not yet received long-term treatment with penicillin had antibodies of the IgG class in two out of 12 cases. The patients gave no history of adverse reactions to the penicillin injections and there were no signs of immune complex-mediated disease. The two children who had IgE antibodies were switched to oral erythromycin instead of the penicillin injections. Penicillin is the drug of choice in the prophylaxis of rheumatic fever and can apparently be safely given as intramuscular injections of depot-penicillin to prevent recurrences of the disease and ensuing cardiac damage.

Serial serum penicillin levels following an injection of benzathine penicillin (12 lakh units) in children of rheumatic heart disease.

In 20 children (mean age 12·0±1·7 years) of rheumatic heart disease, serum penicillin was measured by a microbiological assay on days 1, 7, 14, 18, 21, 23, 25 and 28, first following an IM injection of benzathine penicillin 12 lakh units and then after 3 months of regular monthly injections. The serum penicillin levels were 0·653±0·102 units/ml, 0·063±0·019 units/ml and 0·046±0·025 units/ml on days 1, 7 and 14 respectively. These levels were much above minimum inhibitory concentration (MIC) of penicillin (0·03±·005 units) against β-hemolytic streptococci. A precipitous fall in serum penicillin was observed after day 14. As a result of this the penicillin levels reached below MIC much before the end of the third week of injection. These results are similar to those reported by us in adults and contrast strikingly against those reported by western authors. In view of our results we recommend that for secondary prophylaxis of rheumatic fever in children of RHD injections of benzathine penicillin 12 lakh units should be given once every 3 weeks in our country.

Rheumatic fever and rheumatic heart disease in Barbados: detection and prophylaxis.

The objectives of this study were to improve our methods of secondary prophylaxis of rheumatic fever and rheumatic heart disease in Barbados, to estimate the overall prevalence of these diseases and the relative load imposed by them on available health services, and to measure the yield, feasibility, and effectiveness of mass programmes for the detection and prophylactic management of rheumatic heart disease in schoolchildren.Improved methods of surveillance and follow-up resulted in 97% adherence to therapy by patients on prophylactic penicillin. Thirty-four children, 27 with a first attack, were admitted with acute rheumatic fever, representing a 7% occupancy of children's medical beds during the 12-month period of the study. Out of a possible 3,942 schoolchildren aged 5-11 years, 3,882 (98%) were screened for rheumatic heart disease. Four cases (about 1 per 1,000) were discovered.