Benzathine Penicillin G for the Management of RHD: Concerns About Quality and Access, and Opportunities for Intervention and Improvement

Abstract

Benzathine penicillin G is an important antibiotic for the treatment and prevention of group A streptococcal infections associated with rheumatic fever and rheumatic heart disease. However, as rheumatic heart disease has receded as a public health priority in most high-income settings, attention to the supply, manufacture, and accessibility of benzathine penicillin G has declined. Concerns about the quality, efficacy, and innovation of the drug have emerged following plasma analysis and anecdotal reports from low-resource settings. This review collates core issues in supply and delivery of benzathine penicillin G as a foundation for concerted efforts to improve global quality and access. Opportunities for intervention and improvement are explored.

New developments in anti-malarial target candidate and product profiles

“…Compounds used should have a relatively low susceptibility to resistance generation; breakthrough strains following intramuscular injections of cycloguanil pamoate in children were all resistant [141, 142], presumably due to pre-existing dihydrofolate reductase (DHFR)-resistant parasites in the field. The particle size and viscosity of the vehicle will be important; penicillin-G benzathine as a long-acting antimicrobial is precluded from routine pediatric use because of the required needle size [143]. Potency is important too; in psychiatric disease, drugs suitable for injection have oral adult doses in the 10-mg/day range, and this serves as a useful guide to early candidate identification for the long-acting formulation of an anti-malarial.…”

The WHF Roadmap for Reducing CV Morbidity and Mortality Through Prevention and Control of RHD

“…From the health systems perspective, the delivery of effective primary prevention may be hindered by:  Shortages and stock outs of essential antibiotics, including quality BPG, which may result from inefficient procurement and supply chain management practices, or supply issues at the production/manufacturer level [34],  Poor understanding among health professionals about the purpose of treating sore throat and the link with RHD,  Insufficient knowledge or systems at primary care level for the effective management of sore throat,  Absence of standardised clinical guidelines,  Inadequate training, resources or capacity to act on clinical guidelines which may be due to a lack of practical local clinical guidelines or, where they do exist, ineffective dissemination and uptake of guidelines among health professionals,  Limited geographic coverage of existing primary healthcare services,  Reluctance to administer penicillin out of concern for anaphylaxis [35], resulting in onerous skin testing before administration in some settings and, in other settings, blanket bans on penicillin administration.…”

“…From the health systems perspective:  Clinicians may not have the training or resources to diagnose RF accurately [43],  Lack of local guidelines, or their ineffective implementation can lead to inconsistent diagnosis, treatment and management of patients,  Unreliable supply of quality antibiotics, especially BPG, and injection equipment is an important determinant of non-adherence [34,44],  Concerns about anaphylaxis, particularly among asymptomatic children, may make some health professionals reluctant to administer BPG [35], and in some settings this has led to bans on penicillin administration,  Lack of primary care infrastructure to support delivery of secondary prevention.…”

“…Invented in 1928, this antibiotic has been included on the WHO Essential Medicines List since the first edition was published in 1977. However, several important concerns remain about BPG shortages at production level, efficacy and quality, and persistent stock outs which continue to limit access [34].…”

Is Rheumatic Mitral Valve Disease Still Maintaining its Prevalence in Our Country? Early and Long-term Outcomes After Mitral Valve Replacement with Rheumatic Origin

“…Romatizmal kalp hastalığı sağlığa ulaşımın güç olduğu ülkelerde halen güncel bir sorundur. Ekokardiyografi gibi tanı yöntemlerine erişim kısıtlılığının yanı sıra hastalığın komplikasyonlarının önlenmesinde aktif rol oynayan, 21-28 günde bir kez uygulanan Benzathine penisilin G kullanımının aksadığı ülkelerde yaygın görülmektedir (1)(2)(3)(4)(5) .…”