Medical management
Neeraj Parakh, Ravi S. Math, Vivek Chaturvedi in Mitral Stenosis, 2018
Since rheumatic heart disease is the most common etiology for MS, secondary prevention for rheumatic fever is an essential part of treatment. It is unclear how much MS progression can be delayed by regular secondary prophylaxis. Regular secondary prophylaxis reduces the clinical severity and mortality of mitral regurgitation (MR), prevents involvement of other valves, and decreases the chance of developing MR over pre-existent MS. The progression of MS is a complex process related mostly to the turbulence generated at the valve and subvalvular level. Progressive subvalvular disease and calcification could be related to rheumatic fever recurrence, but there is a lack of clear documentation in prospective studies. Intramuscular benzathine penicillin reduces streptococcal pharyngitis by 71%–91% and reduces recurrent rheumatic fever by 87%–96%.9Table 11.2 describes various antibiotic regimens for secondary prevention of rheumatic fever. Patients with persistent valvular disease should receive prophylaxis for 10 years after the last episode of acute rheumatic fever or until 40 years of age, whichever is longer. Some high-risk patients may require longer (even lifelong) prophylaxis, depending upon the severity of valvular disease and the potential for exposure to group A streptococci.
Phenoxypenicillins
M. Lindsay Grayson, Sara E. Cosgrove, Suzanne M. Crowe, M. Lindsay Grayson, William Hope, James S. McCarthy, John Mills, Johan W. Mouton, David L. Paterson in Kucers’ The Use of Antibiotics, 2017
Long-term administration of penicillin is recommended for patients who have had prior rheumatic fever to prevent recurrence of the disease (Leading article, 1982). Intramuscular injections of 1.2 million units (0.9 g) of benzathine penicillin G can also be used for this purpose (see Chapter 3, Benzylpenicillin (Penicillin G)), but it now seems that these injections should be given once every 2 weeks. If compliance can be ensured, oral chemotherapy is often preferred, in which case Pen V or amoxicillin is recommended (Garrod, 1975). The usual adult Pen V dosage is 500 mg daily given in two divided doses. In patients receiving long-term penicillin chemoprophylaxis, oral S. viridans strains often become penicillin resistant (Parrillo et al., 1979), and drugs other than one of the penicillins should be used for endocarditis prophylaxis. The current Australian national guidelines recommend benzathine penicillin 900 mg for adults and children ≥ 20 kg) or 450 mg for children < 20 kg), i.m. every 3–4 weeks as first preference, especially in remote communities; Pen V 250 mg every 12 hours is an alternative. A regimen of benzathine penicillin every 3 weeks is preferred in patients who have had a confirmed breakthrough of acute rheumatic fever despite a regimen of benzathine penicillin every 4 weeks. The duration of prophylaxis depends on the severity and frequency of rheumatic fever episodes (Antibiotic Expert Group, 2014). The 2009 US guidelines also support this approach (Gerber et al. 2009).
Sexually Transmitted Diseases
Peter Sagar, Andrew G. Hill, Charles H. Knowles, Stefan Post, Willem A. Bemelman, Patricia L. Roberts, Susan Galandiuk, John R.T. Monson, Michael R.B. Keighley, Norman S. Williams in Keighley & Williams’ Surgery of the Anus, Rectum and Colon, 2019
Penicillin G, administered parenterally, is the preferred drug for treating persons in all stages of syphilis. The preparation used (i.e. benzathine, aqueous procaine or aqueous crystalline), dosage and length of treatment depend on the stage and clinical manifestations of the disease. For early syphilis, benzathine penicillin G 2.4 million units administered intramuscularly in a single dose is the recommended treatment. Stage and clinical presentation further determine the preparation, dosage and length of treatment. Additional medications, such as azithromycin and ceftriaxone, may have a role in management.26 The management of tertiary syphilis, pregnant women with syphilis and congenital syphilis is beyond the scope of this chapter. More information on syphilis in these settings, as well as treatment recommendations, can be obtained from the CDC Morbidity and Mortality Weekly Report.2 There is no strong evidence to support prolonged or augmented therapy in treating syphilis in patients who are HIV positive.1,27
Treatment outcomes of acute streptococcal tonsillitis according to antibiotic treatment. A retrospective analysis of 242,366 cases treated in the community
Published in European Journal of General Practice, 2022
Mattan Bar-Yishay, Ilan Yehoshua, Avital Bilitzky, Yan Press
Various studies have shown similar efficacy of amoxicillin and penicillin-V in successfully treating GABHS pharyngitis [14–16]. Since then, once-daily amoxicillin has been prescribed often [6], especially among children, presumably due to ease of administration and preferably tasting formulation. By comparison, IM benzathine penicillin is administered far less frequently. A single IM injection of benzathine penicillin is a long-acting treatment, with detectable levels of penicillin found in serum and tonsils for up to four weeks following injection [17]. Interestingly, benzathine penicillin is the only antibiotic therapy that has been shown to prevent acute rheumatic fever in controlled studies [18–20]; however, these were conducted in the 1950s. The few studies that have compared IM benzathine penicillin treatment to oral amoxicillin have reported superior GABHS eradication rates among children in low-resource countries [21,22], presumably due to increased compliance. Additional studies comparing benzathine penicillin to other antibiotics demonstrated similar clinical and biological cure rates between treatment groups [23,24]. However, despite efficiency, wide availability and low cost, benzathine penicillin is rarely utilised in the primary treatment of acute GABHS pharyngitis in high-resource community settings. The discomforts to patient, physician and parent associated with an IM injection are assumed to be the cause of low utilisation in high-resource countries, where compliance and rheumatic sequels are of less concern.
Epithelial dysfunction, respiratory infections and asthma: the importance of immunomodulation. A focus on OM-85
Published in Expert Review of Respiratory Medicine, 2020
Fabio Cardinale, Enrico Lombardi, Oliviero Rossi, Diego Bagnasco, Aldo Bellocchi, Francesco Menzella
Children with recurrent RTIs commonly are not affected by immune defects and these infections may simply represent increased exposure to infectious agents during the first years of life, when immune function is still immature [19]. However, children with selective antibody deficiency may be at higher risk for recurrent infection [20]. In 87 children with IgA and IgG subclass deficiencies, 76% presented with recurrent upper RTIs. A number of 68 (78%) of patients received prophylactic treatment with benzathine penicillin, prophylactic oral antibiotic, or oral bacterial extract and these patients suffered 2.5 ± 2.3 infections/year compared to 7.9 ± 4.9 infections/year in children without any prophylactic regimen [21]. This decrease in frequency did not show any significant difference between different prophylactic groups. Serum IgA recovered to normal range in 52% of children with partial IgA deficiency and serum IgG recovered to of normal range in 67% of children with IgG plus IgA subclass deficit and 30% of children with isolated subclass deficits.
Vasculitis in a case of rupioid syphilis in HIV
Published in Baylor University Medical Center Proceedings, 2022
Connor Rodriguez, Parneet Dhaliwal, Allison Readinger
Aspiration of the left knee was initially concerning for infection, and the patient was started on empiric antibiotics, but routine cultures were later determined to be negative. Dermatology was consulted and performed a punch biopsy of the skin. Histology demonstrated an abscess with medium- to large-sized blood vessels with fibrinoid necrosis of the vessel wall and neutrophilic infiltrate in and around the vessel walls (Figure 1b). Grocott methenamine silver, acid-fast bacilli, and Gram stains were negative for organisms as well as spirochete immunostain and human herpesvirus-8, likely due to treatment with empiric antibiotics. After communication between the clinician and the pathologist, with review of clinical lesions and pathologic findings, serologic testing was performed, showing a positive rapid plasma reagin (RPR) (1:128 titer), consistent with syphilis. The patient was started on intravenous benzathine penicillin G. He was continued on penicillin at his 4-week follow-up visit. The patient’s lesions resolved the next month with no recurrence.
Related Knowledge Centers
- Antibiotic
- Diphtheria
- Intramuscular Injection
- Rheumatic Fever
- Streptococcal Pharyngitis
- Yaws
- Anaphylaxis
- Allergy
- Syphilis
- Pathogenic Bacteria