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Regmi PR, Dhungel M, Kafle R. Secondary Prevention of Rheumatic Heart Disease in Nepal: Are We Going Backward? JNMA J Nepal Med Assoc 2022; 60:832-835. [PMID: 36705119 PMCID: PMC9794947 DOI: 10.31729/jnma.7861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Indexed: 01/31/2023] Open
Abstract
A secondary level of prophylaxis has proven to be the most successful in Nepal, a country with an endemic rate of rheumatic heart disease, in combating the severe issues associated with rheumatic heart disease. The use of benzathine penicillin G in secondary prophylaxis of rheumatic heart disease, recommended by several guidelines, has been increasingly abandoned in Nepal due to a lack of national guidelines and the termination of the prior programs. The use of oral penicillin and alternative oral antibiotics, which are less effective in preventing the recurrence of acute rheumatic fever, is on the rise. Nepal urgently needs to develop new national guidelines and ensure their effective implementation in order to slow the increase in the number of rheumatic heart disease patients. In this article, we explore the limitations, challenges, and advantages of using the consensus-supported intramuscular benzathine penicillin G as the first-line drug for the secondary prevention of rheumatic heart disease.
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Affiliation(s)
- Prakash Raj Regmi
- Nepal Heart Foundation, Pulchowk, Lalitpur, Nepal,Correspondence: Dr Prakash Raj Regmi, Nepal Heart Foundation, Pulchowk, Lalitpur, Nepal. , Phone: +977-9851051170
| | | | - Riju Kafle
- Nepal Heart Foundation, Pulchowk, Lalitpur, Nepal
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Zabala GA, Bellingham K, Vidhamaly V, Boupha P, Boutsamay K, Newton PN, Caillet C. Substandard and falsified antibiotics: neglected drivers of antimicrobial resistance? BMJ Glob Health 2022; 7:bmjgh-2022-008587. [PMID: 35981806 PMCID: PMC9394205 DOI: 10.1136/bmjgh-2022-008587] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/10/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Antimicrobial resistance (AMR) is a significant global health threat with substandard and falsified (SF) antibiotics being neglected contributing factors. With their relationships poorly understood, more research is needed in order to determine how interventions to reduce SF antibiotics should be ranked as priorities in national AMR action plans. We assessed the evidence available on the global prevalence of SF antibiotics, examined the quality of the evidence and discussed public health impact. MATERIALS/METHODS We searched PubMed, Embase, Google and Google Scholar for publications on antibiotic quality up to 31 December 2020. Publications reporting on the prevalence of SF antibiotics were evaluated for quantitative analysis and assessed using the Medicines Quality Assessment Reporting Guidelines. RESULTS Of the 10 137 screened publications, 648 were relevant to antibiotic quality. One hundred and six (16.4%) surveys, published between 1992 and 2020 and conducted mainly in low-income and middle-income countries (LMICs) (89.9% (480/534) of the data points), qualified for quantitative analysis. The total number of samples tested for quality in prevalence surveys was 13 555, with a median (Q1-Q3) number of samples per survey of 47 (21-135). Of the 13 555 samples, 2357 (17.4%) failed at least one quality test and the median failure frequency (FF) per survey was 19.6% (7.6%-35.0%). Amoxicillin, sulfamethoxazole-trimethoprim and ciprofloxacin were the most surveyed antibiotics, with FF of 16.1% (355/2208), 26.2% (329/1255) and 10.4% (366/3511), respectively. We identified no SF survey data for antibiotics in the WHO 'Reserve' group. The mean Medicine Quality Assessment Reporting Guidelines score was 11 (95% CI 10.1 to 12.2) out of 26. CONCLUSIONS SF antibiotics are widely spread with higher prevalence in LMICs. The quality of the evidence is poor, and these data are not generalisable that 17.4% of global antibiotic supply is SF. However, the evidence we have suggests that interventions to enhance regulatory, purchasing and financial mechanisms to improve the global antibiotic supply are needed. PROSPERO REGISTRATION NUMBER CRD42019124988.
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Affiliation(s)
- Guillermo A Zabala
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Clinical Infection Unit, Saint George's University Hospital NHS Foundation Trust, London, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Khonsavath Bellingham
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Vayouly Vidhamaly
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Phonepasith Boupha
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Kem Boutsamay
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic.,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
| | - Céline Caillet
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Medicine Quality Research Group, Laboratory of Microbiology, Mahosot Hospital, Vientiane, Lao People's Democratic Republic .,Nuffield Department of Medicine, Medicine Quality Research Group, University of Oxford Centre for Tropical Medicine and Global Health, Oxford, UK.,Nuffield Department of Medicine, Infectious Diseases Data Observatory (IDDO)/WorldWide Antimalarial Resistance Network (WWARN), Medicine Quality Research Group, University of Oxford, Oxford, UK
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Batty KT, Page-Sharp M, Salman S, Hla TK, Manning L. Stability of benzylpenicillin for continuous intravenous infusions: An isotonic formulation for therapeutic use and a low-dose formulation for clinical trial. J Infect Chemother 2022; 28:1225-1230. [PMID: 35637131 DOI: 10.1016/j.jiac.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The objectives of this study were to develop a stability-indicating high performance liquid chromatography (HPLC) assay for benzylpenicillin (BPC) in pharmaceutical fluids, and to investigate the stability of (i) isotonic citrate-buffered BPC solutions at the clinically relevant concentration of 30 mg/mL, and (ii) low concentration citrate-buffered BPC intravenous infusions (5-30 μg/mL). METHODS The stability of isotonic BPC solutions containing 3.4 or 7.2 mg/mL sodium citrate was compared against contemporary hypertonic solutions. The HPLC assay was shown to be stability-indicating following acidic, alkali, oxidative and elevated temperature stress testing. RESULTS After 7 d storage at 4 °C and 24 h at 35 °C, the concentrations of isotonic BPC 30 mg/mL solutions containing 3.4 and 7.2 mg/mL sodium citrate were 96% and 95% respectively, compared to day 0. After 3 d at 4 °C and 24 h at room temperature (22 °C), the concentrations of isotonic BPC solutions with 3.4 and 7.2 mg/mL sodium citrate were 99% and 96% respectively, compared to day 0. These data were comparable to the hypertonic solutions and meet pharmacopeial stability requirements. Low concentration BPC infusions showed 0.5% and 2.5% degradation after 24 h storage at 22 °C and 35 °C, respectively. CONCLUSIONS The isotonic BPC 30 mg/mL formulation is simple to prepare and may offer clinical benefits in settings where hypertonic solutions are problematic. This study provides assurance that high- and low-dose isotonic BPC infusions are stable at room temperature and our findings may be applicable to in vitro studies of BPC.
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Affiliation(s)
- Kevin T Batty
- Curtin Medical School, Curtin University, Bentley, WA, 6102, Australia; Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, 6102, Australia.
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, WA, 6102, Australia.
| | - Sam Salman
- Medical School, University of Western Australia, Crawley, WA, 6009, Australia.
| | - Thel K Hla
- Medical School, University of Western Australia, Crawley, WA, 6009, Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, 6009, Australia.
| | - Laurens Manning
- Medical School, University of Western Australia, Crawley, WA, 6009, Australia.
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Kotit S, Phillips DIW, Afifi A, Yacoub M. The "Cairo Accord"- Towards the Eradication of RHD: An Update. Front Cardiovasc Med 2021; 8:690227. [PMID: 34277735 PMCID: PMC8282907 DOI: 10.3389/fcvm.2021.690227] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/07/2021] [Indexed: 01/18/2023] Open
Abstract
Rheumatic heart disease (RHD) is the most common cause of acquired heart disease in children and young adults. It continues to be prevalent in many low- and middle-income countries where it causes significant morbidity and mortality. Following the 2017 Cairo conference "Rheumatic Heart Disease: from Molecules to the Global Community," experts from 21 countries formulated an approach for addressing the problem of RHD: "The Cairo Accord on Rheumatic Heart Disease." The Accord attempts to set policy priorities for the eradication of acute rheumatic fever (ARF) and RHD and builds on a recent series of policy initiatives and calls to action. We present an update on the recommendations of the Cairo Accord and discuss recent progress toward the eradication of RHD, including contributions from our own Aswan Rheumatic Heart Disease Registry (ARGI).
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Affiliation(s)
| | - David I. W. Phillips
- Developmental Origins of Health and Disease Division, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | | | - Magdi Yacoub
- Aswan Heart Centre, Aswan, Egypt
- Heart Science Centre, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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High risk of early sub-therapeutic penicillin concentrations after intramuscular benzathine penicillin G injections in Ethiopian children and adults with rheumatic heart disease. PLoS Negl Trop Dis 2021; 15:e0009399. [PMID: 34115748 PMCID: PMC8195421 DOI: 10.1371/journal.pntd.0009399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/21/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Intramuscular benzathine penicillin G (BPG) injections are a cornerstone of secondary prophylaxis to prevent acute rheumatic fever (ARF) and rheumatic heart disease (RHD). Uncertainties regarding inter-ethnic and preparation variability, and target exposure profiles of BPG injection are key knowledge gaps for RHD control. Methods To evaluate BPG pharmacokinetics (PK) in patients receiving 4-weekly doses in Ethiopia, we conducted a prospective cohort study of ARF/RHD patients attending cardiology outpatient clinics. Serum samples were collected weekly for one month after injection and assayed with a liquid chromatography-mass spectroscopy assay. Concentration-time datasets for BPG were analyzed by nonlinear mixed effects modelling using NONMEM. Results A total of 190 penicillin concentration samples from 74 patients were included in the final PK model. The median age, weight, BMI was 21 years, 47 kg and 18 kg/m2, respectively. When compared with estimates derived from Indigenous Australian patients, the estimate for median (95% confidence interval) volume of distribution (V/F) was lower (54.8 [43.9–66.3] l.70kg-1) whilst the absorption half-life (t1/2-abs2) was longer (12.0 [8.75–17.7] days). The median (IQR) percentage of time where the concentrations remained above 20 ng/mL and 10 ng/mL within the 28-day treatment cycle was 42.5% (27.5–60) and 73% (58.5–99), respectively. Conclusions The majority of Ethiopian patients receiving BPG as secondary prophylaxis to prevent RHD do not attain target concentrations for more than two weeks during each 4-weekly injection cycle, highlighting the limitations of current BPG strategies. Between-population variation, together with PK differences between different preparations may be important considerations for ARF/RHD control programs. Rheumatic heart disease (RHD) is the most common form of acquired heart disease in Ethiopia across all age groups. Monthly benzathine penicillin G (BPG) injections remains the cornerstone of secondary prophylaxis to prevent recurrent acute rheumatic fever (ARF) and progression to RHD, but data supporting the optimal dose and timing of BPG injections is a major knowledge gap for National RHD control programs, particularly amongst the highest risk groups. In this study we measured penicillin concentrations in Ethiopian patients receiving regular BPG injections. It demonstrates that that most Ethiopian patients receiving BPG as secondary prophylaxis to prevent RHD do not maintain target concentrations for more than two weeks during each 4-weekly injection cycle. This study highlights the limitation of the current BPG dosing recommendations and underpin global calls for improved penicillin formulations and better dosing and delivery strategies.
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