From the Guidelines
Benzathine penicillin G injections are the recommended monthly treatment for rheumatic heart disease (RHD) prevention, with a standard regimen of 1.2 million units administered intramuscularly every 4 weeks. The dosage and administration frequency are crucial in preventing recurrent episodes of rheumatic fever, which can lead to further heart valve damage. According to the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1, the recommended dosage for penicillin G benzathine is 1.2 million U intramuscularly every 4 weeks.
Key Considerations
- The duration of rheumatic fever prophylaxis should be at least 10 years or until the patient is 40 years of age (whichever is longer) 1.
- Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure.
- Secondary rheumatic heart disease prophylaxis is required even after valve replacement.
- Administration every 3 weeks is recommended in certain high-risk situations 1.
Alternative Options
- For patients allergic to penicillin, alternative antibiotics such as sulfadiazine or macrolide/azalide antibiotics may be used, but with careful consideration of potential interactions and side effects 1.
- Oral penicillin V potassium (250 mg twice daily) is another option, but it requires more frequent dosing and may have lower adherence rates compared to intramuscular benzathine penicillin G.
Monitoring and Follow-up
Regular cardiac follow-up with echocardiography is essential to monitor valve function and detect any potential complications early on. Adherence to the monthly regimen is crucial as it significantly reduces the risk of disease progression and complications like heart failure.
From the FDA Drug Label
Following an acute attack, penicillin G benzathine (parenteral) may be given in doses of 1,200,000 units once a month or 600,000 units every 2 weeks. For prophylaxis of rheumatic fever, a monthly injection of 1,200,000 units of penicillin G benzathine can be administered. 2
From the Research
Monthly Injection for Rheumatic Heart Disease
- The current management of rheumatic heart disease (RHD) includes secondary antibiotic prevention, which comprises regular 3 to 4 weekly long-acting intramuscular benzathine penicillin injections 3.
- A study found that subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for RHD secondary prophylaxis, with a potential for up to 3 monthly dosing intervals 4.
- Another study compared the efficacy of injections of 1.2 million units of benzathine penicillin G given every 3 weeks versus every 4 weeks for secondary prevention of rheumatic fever, and found that the 3-week regimen was more effective in reducing the risk of recurrence of rheumatic fever and progression of RHD 5.
- A systematic review found that antibiotic prophylaxis likely reduces the risk of recurrence of rheumatic fever compared to no antibiotics, and that intramuscular benzathine benzylpenicillin is probably superior to oral antibiotics 6.
- A Cochrane review found that intramuscular penicillin seemed to be more effective than oral penicillin in preventing rheumatic fever recurrence and streptococcal throat infections, and that 2-weekly or 3-weekly injections appeared to be more effective than 4-weekly injections 7.
Key Findings
- Monthly injection of benzathine penicillin G may be a suitable option for RHD secondary prophylaxis 4.
- The frequency of benzathine penicillin injections can impact the effectiveness of RHD secondary prophylaxis, with more frequent injections potentially leading to better outcomes 5, 7.
- Antibiotic prophylaxis is likely to reduce the risk of recurrence of rheumatic fever and progression of RHD, with intramuscular benzathine benzylpenicillin being a potentially effective option 6.