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Kado J, Salman S, Hla TK, Enkel S, Henderson R, Hand RM, Hort A, Page-Sharp M, Batty K, Moore BR, Bennett J, Anderson A, Carapetis J, Manning L. Subcutaneous infusion of high-dose benzathine penicillin G is safe, tolerable, and suitable for less-frequent dosing for rheumatic heart disease secondary prophylaxis: a phase 1 open-label population pharmacokinetic study. Antimicrob Agents Chemother 2023; 67:e0096223. [PMID: 37971244 PMCID: PMC10720493 DOI: 10.1128/aac.00962-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023] Open
Abstract
Since 1955, the recommended strategy for rheumatic heart disease (RHD) secondary prophylaxis has been benzathine penicillin G [BPG; 1.2 MU (900 mg)] injections administered intramuscularly every 4 weeks. Due to dosing frequency, pain, and programmatic challenges, adherence is suboptimal. It has previously been demonstrated that BPG delivered subcutaneously at a standard dose is safe and tolerable and has favorable pharmacokinetics, setting the scene for improved regimens with less frequent administration. The safety, tolerability, and pharmacokinetics of subcutaneous infusions of high-dose BPG were assessed in 24 healthy adult volunteers assigned to receive either 3.6, 7.2, or 10.8 MU (three, six, and nine times the standard dose, respectively) as a single subcutaneous infusion. The delivery of the BPG to the subcutaneous tissue was confirmed with ultrasonography. Safety assessments, pain scores, and penicillin concentrations were measured for 16 weeks post-dose. Subcutaneous infusion of penicillin (SCIP) was generally well tolerated with all participants experiencing transient, mild infusion-site reactions. Prolonged elevated penicillin concentrations were described using a combined zero-order (44 days) and first-order (t1/2 = 12 days) absorption pharmacokinetic model. In simulations, time above the conventionally accepted target concentration of 20 ng/mL (0.02 µg/mL) was 57 days for 10.8 MU delivered by subcutaneous infusion every 13 weeks compared with 9 days of every 4-weekly dosing interval for the standard 1.2 MU intramuscular dose (i.e., 63% and 32% of the dosing interval, respectively). High-dose SCIP (BPG) is safe, has acceptable tolerability, and may be suitable for up to 3 monthly dosing intervals for secondary prophylaxis of RHD.
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Affiliation(s)
- Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Thel K. Hla
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Stephanie Enkel
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Henderson
- Medical Imaging Department, Perth Children’s Hospital, Nedlands, Western Australia, Australia
| | - Robert M. Hand
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Adam Hort
- Western Australian Country Health Service, Perth, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Kevin Batty
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Brioni R. Moore
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Bentley, Western Australia, Australia
| | - Julie Bennett
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Anneka Anderson
- Te Kupenga Hauora Maori, University of Auckland, Auckland, New Zealand
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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2
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Barr RK, Barber BW, Tait JR, Landersdorfer CB, Salman S, Musk GC, Page-Sharp M, Batty KT, Kado J, Manning L, Carapetis JR, Boyd BJ. Development of a sustained release implant of benzathine penicillin G for secondary prophylaxis of rheumatic heart disease. Eur J Pharm Biopharm 2023:S0939-6411(23)00159-5. [PMID: 37354997 DOI: 10.1016/j.ejpb.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/21/2023] [Accepted: 06/12/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Regular intramuscular (i.m.) benzathine penicillin G (BPG) injections have been the cornerstone of rheumatic heart disease (RHD) secondary prophylaxis since the 1950s. Patient adherence to IM BPG is poor, largely due to pain, the need for regular injections every 3-4 weeks and health sector delivery challenges in resource-limited settings. There is an urgent need for new approaches for secondary prophylaxis, such as an implant which could provide sustained penicillin concentrations for more than 6 months. METHODS In this study we developed and evaluated a slow release implant with potential for substantially extended treatment. The side wall of a solid drug rich core was coated with polycaprolactone which acts as an impermeable barrier. The exposed surfaces at the ends of the implant defined the release surface area, and the in vitro release rate of drug was proportional to the exposed surface area across implants of differing diameter. The in vivo pharmacokinetics and tolerability of the implants were evaluated in a sheep model over 9 weeks after subcutaneous implantation. RESULTS The absolute release rates obtained for the poorly water-soluble benzathine salt were dependent on the exposed surface area demonstrating the impermeability of the wall of the implant. The implants were well-tolerated after subcutaneous implantation in a sheep model, without adverse effects at the implantation site. Gross structural integrity was maintained over the course of the study, with erosion limited to the dual-exposed ends. Steady release of penicillin G was observed over the 9 weeks and resulted in approximately constant plasma concentrations close to accepted target concentrations. CONCLUSION In principle, a long acting BPG implant is feasible as an alternative to IM injections for secondary prophylaxis of RHD. However, large implant size is currently a significant impediment to clinical utility and acceptability.
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Affiliation(s)
- Renae K Barr
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
| | - Bryce W Barber
- Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | - Jessica R Tait
- Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia
| | | | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; Clinical Pharmacology and Toxicology Unit, PathWest Laboratory Medicine, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Gabrielle C Musk
- Animal Care Services, University of Western Australia, Crawley, WA, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Kevin T Batty
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia; Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia4.
| | - Ben J Boyd
- Monash Institute of Pharmaceutical Sciences, Parkville, VIC, Australia; University of Copenhagen Department of Pharmacy, University of Copenhagen Universitetsparken 2, 2100 Copenhagen, Denmark.
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Acute Rheumatic Fever: Recent Advances. Pediatr Infect Dis J 2023; 42:e42-e44. [PMID: 36102715 DOI: 10.1097/inf.0000000000003708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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4
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Hla TK, Osowicki J, Salman S, Batty KT, Marsh JA, Kado J, Barr R, Enkel SL, Snelling TL, McCarthy J, Steer AC, Carapetis J, Manning L. Study protocol for controlled human infection for penicillin G against Streptococcus pyogenes: a double-blinded, placebo-controlled, randomised trial to determine the minimum concentration required to prevent experimental pharyngitis (the CHIPS trial). BMJ Open 2022; 12:e064022. [PMID: 36600395 PMCID: PMC9743388 DOI: 10.1136/bmjopen-2022-064022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Regular intramuscular benzathine penicillin G injections have been the cornerstone of rheumatic heart disease (RHD) secondary prophylaxis since the 1950s. As the pharmacological correlate of protection remains unknown, it is difficult to recommend changes to this established regimen. Determining the minimum effective penicillin exposure required to prevent Streptococcus pyogenes infection will accelerate development of new long-acting penicillins for RHD prevention as well as inform opportunities to improve existing regimens. The CHIPS trial will address this knowledge gap by directly testing protection afforded by different steady state plasma concentrations of penicillin in an established model of experimental human S. pyogenes pharyngitis. METHODS AND ANALYSIS This is a double-blinded, placebo-controlled, randomised experimental human infection study. Sixty healthy adult volunteers aged 18-40 years will be recruited and randomised 1:1:1:1:1 to continuous intravenous penicillin infusions targeting five different steady state plasma concentrations of 0 (placebo), 3, 6, 12 and 20 ng/mL via a midline catheter. Each participant's penicillin pharmacokinetic parameters will be established prior to the challenge, to ensure accurate dosing for the continuous infusion. Following the challenge with a well-characterised strain of S. pyogenes, participants will be observed for up to 6 days for the development of pharyngitis and treated with antibiotics prior to discharge. The primary objective is to determine the minimum effective steady-state plasma penicillin concentration required to prevent experimental pharyngitis. Secondary objectives will explore systemic and mucosal immunoinflammatory responses during pharyngitis, bacterial colonisation dynamics, environmental contamination and qualitative evaluation of the participant experience. ETHICS AND DISSEMINATION Ethical approval has been obtained (Bellberry Human Research Ethics Committee). Findings will be reported in peer-reviewed publications and presented at national/international stakeholder forums. TRIAL REGISTRATION NUMBER ACTRN12621000751875.
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Affiliation(s)
- Thel Khin Hla
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Joshua Osowicki
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Infectious Diseases Unit, Royal Children's Hospital Melbourne Department of General Medicine, Parkville, Victoria, Australia
| | - Sam Salman
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Kevin T Batty
- Curtin University, Perth, Western Australia, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Joseph Kado
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Renae Barr
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Stephanie L Enkel
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Thomas L Snelling
- The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | | | - Andrew C Steer
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Infectious Diseases Unit, Royal Children's Hospital Melbourne Department of General Medicine, Parkville, Victoria, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
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Ralph AP, Kelly A, Lee AM, Mungatopi VL, Babui SR, Budhathoki NK, Wade V, de Dassel JL, Wyber R. Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191610215. [PMID: 36011846 PMCID: PMC9407981 DOI: 10.3390/ijerph191610215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/02/2022] [Accepted: 08/14/2022] [Indexed: 06/09/2023]
Abstract
Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.
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Affiliation(s)
- Anna P. Ralph
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin 0810, Australia
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | - Angela Kelly
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Anne-Marie Lee
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
- Sunrise Health Corporation, Katherine 0850, Australia
| | - Valerina L. Mungatopi
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Segora R. Babui
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Nanda Kaji Budhathoki
- Menzies School of Health Research, Charles Darwin University, Darwin 0810, Australia
| | - Vicki Wade
- Rheumatic Heart Disease Australia, Menzies School of Health Research, Darwin 0810, Australia
| | | | - Rosemary Wyber
- Telethon Kids Institute, Perth 6000, Australia
- George Institute for Global Health, Sydney 2000, Australia
- Australian National University, Canberra 2610, Australia
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6
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Kado J, Salman S, Hand R, O'Brien M, Ralph A, Bowen AC, Page-Sharp M, Batty KT, Dolman V, Francis JR, Carapetis J, Manning L. Population pharmacokinetic study of benzathine penicillin G administration in Indigenous children and young adults with rheumatic heart disease in the Northern Territory, Australia. J Antimicrob Chemother 2022; 77:2679-2682. [PMID: 35822635 DOI: 10.1093/jac/dkac231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Benzathine penicillin G (BPG) is the cornerstone of secondary prophylaxis to prevent Streptococcus pyogenes infections, which precede acute rheumatic fever (ARF). The paucity of pharmacokinetic (PK) data from children and adolescents from populations at the highest risk of ARF and rheumatic heart disease (RHD) poses a challenge for determining the optimal dosing and frequency of injections and undermines efforts to develop improved regimens. METHODS We conducted a 6 month longitudinal PK study of young people receiving BPG for secondary prophylaxis. Throat and skin swabs were collected for microbiological culture along with dried blood spot (DBS) samples for penicillin concentrations. DBSs were assayed using LC-MS/MS. Penicillin concentration datasets were analysed using non-linear mixed-effects modelling and simulations performed using published BMI-for-age and weight-for-age data. RESULTS Nineteen participants provided 75 throat swabs, 3 skin swabs and 216 penicillin samples. Throat cultures grew group C and G Streptococcus. Despite no participant maintaining penicillin concentration >20 ng/mL between doses, there were no S. pyogenes throat infections and no ARF. The median (range) observed durations >20 ng/mL for the low- and high-BMI groups were 14.5 (11.0-24.25) and 15.0 (7.5-18.25) days, respectively. CONCLUSIONS Few patients at highest risk of ARF/RHD receiving BPG for secondary prophylaxis maintain penicillin concentrations above the target of 20 ng/mL beyond 2 weeks during each monthly dosing interval. These PK data suggest that some high-risk individuals may get inadequate protection from every 4 week dosing. Future research should explore this gap in knowledge and PK differences between different populations to inform future dosing schedules.
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Affiliation(s)
- Joseph Kado
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Medical School, University of Western Australia, Perth, WA, Australia
| | - Sam Salman
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Medical School, University of Western Australia, Perth, WA, Australia.,Clinical Pharmacology and Toxicology Unit, PathWest, Perth, WA, Australia
| | - Robert Hand
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Department of Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia
| | - Margaret O'Brien
- Danila Dilba Health Service, Darwin, NT, Australia.,National Centre for Epidemiology and Population Health, Australia National University, Canberra, ACT, Australia.,Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Anna Ralph
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Medical School, University of Western Australia, Perth, WA, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Madhu Page-Sharp
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Kevin T Batty
- Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Veronica Dolman
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Joshua R Francis
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Medical School, University of Western Australia, Perth, WA, Australia.,Curtin Medical School, Curtin University, Bentley, WA, Australia
| | - Laurens Manning
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Medical School, University of Western Australia, Perth, WA, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, 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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8
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Kado JH, Salman S, Henderson R, Hand R, Wyber R, Page-Sharp M, Batty K, Carapetis J, Manning L. Subcutaneous administration of benzathine benzylpenicillin G has favourable pharmacokinetic characteristics for the prevention of rheumatic heart disease compared with intramuscular injection: a randomized, crossover, population pharmacokinetic study in healthy adult volunteers. J Antimicrob Chemother 2021; 75:2951-2959. [PMID: 32696033 DOI: 10.1093/jac/dkaa282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Benzathine penicillin G has been used as monthly deep intramuscular (IM) injections since the 1950s for secondary prevention of acute rheumatic fever and rheumatic heart disease (RHD). Injection frequency and pain are major programmatic barriers for adherence, prompting calls for development of better long-acting penicillin preparations to prevent RHD. We hypothesized that subcutaneous (SC) administration of benzathine penicillin G could delay penicillin absorption when compared with IM injections. METHODS To compare the pharmacokinetic profile and tolerability of benzathine penicillin G according to different routes of administration, 15 healthy males participated in a randomized crossover study to receive benzathine penicillin G by either SC or IM routes, with a 10 week washout period before the second dose by the alternative route. Ultrasound guidance confirmed injection location. Penicillin concentrations and pain scores were measured for 6 weeks following injections. RESULTS SC administration was well tolerated with no significant differences in pain scores. Following SC injection, the principal absorption half-life (95% CI) was 20.1 (16.3-29.5) days and 89.6% (87.1%-92.0%) of the drug was directed via this pathway compared with 10.2 (8.6-12.5) days and 71.3% (64.9%-77.4%) following IM administration. Lower peak and higher trough penicillin concentrations resulted following SC injection. Simulations demonstrated that SC infusion of higher doses of benzathine penicillin G could provide therapeutic penicillin concentrations for 3 months. CONCLUSIONS SC administration of benzathine penicillin G is safe and significantly delays penicillin absorption. High-dose benzathine penicillin G via the SC route would fulfil many product characteristics required for the next generation of longer-acting penicillins for use in RHD.
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Affiliation(s)
- Joseph H Kado
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sam Salman
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Henderson
- Department of Radiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Robert Hand
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Rosemary Wyber
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,The George Institute of Global Health, University of Sydney, Sydney, New South Wales, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Kevin Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.,Fiona Stanley Hospital, Murdoch, WA 6150, Australia
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9
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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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Hand RM, Senarathna SMDKG, Page‐Sharp M, Gray K, Sika‐Paotonu D, Sheel M, Chuang VTG, Martinez J, Luna G, Manning L, Wyber R, Carapetis JR, Batty KT. Quality of benzathine penicillin G: A multinational cross-sectional study. Pharmacol Res Perspect 2020; 8:e00668. [PMID: 33090729 PMCID: PMC7580708 DOI: 10.1002/prp2.668] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 01/10/2023] Open
Abstract
Benzathine penicillin G (BPG) is used as first-line treatment for most forms of syphilis and as secondary prophylaxis against rheumatic heart disease (RHD). Perceptions that poor quality of BPG is linked to reported adverse effects and therapeutic failure may impact syphilis and RHD control programs. Clinical networks and web-based advertising were used to obtain vials of BPG from a wide range of countries. The quality of BPG was assessed using a high performance liquid chromatography assay capable of detecting relevant impurities and degradation products. Tests for water content, presence of heavy metals and physical characteristics of BPG, including particle size analysis and optical microscopy, also were conducted. Thirty-five batches of BPG were sourced from 16 countries across 4 WHO regions. All batches passed the US Pharmacopeia requirements for BPG injection (content), with no evidence of breakdown products or other detected contaminants. Water content and heavy metal analysis (n = 11) indicated adherence to regulatory standards and Good Manufacturing Practice. Particle size analysis (n = 20) found two batches with aggregated particles (>400 µm) that were dispersed following sonication. Current batches of BPG were of satisfactory pharmaceutical quality but aggregated particles were found in a modest proportion of samples. Future studies should focus on the physical characteristics of BPG which may contribute to variations in plasma penicillin concentrations an observed needle blockages in clinical practice. Pharmacopeial monographs could be revised to include standards on particle size and crystal morphology of BPG.
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Affiliation(s)
- Robert M. Hand
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | | | - Madhu Page‐Sharp
- School of Pharmacy and Biomedical SciencesCurtin UniversityBentleyWestern AustraliaAustralia
| | - Katherine Gray
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Dianne Sika‐Paotonu
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
- Dean’s Department and Department of Pathology & Molecular MedicineWellington School of Medicine and Health SciencesUniversity of OtagoDunedinNew Zealand
- Faculty of HealthVictoria University of WellingtonWellingtonNew Zealand
- Maurice Wilkins Centre for Molecular BiodiscoveryUniversity of AucklandAucklandNew Zealand
| | - Meru Sheel
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | | | - Jorge Martinez
- School of Pharmacy and Biomedical SciencesCurtin UniversityBentleyWestern AustraliaAustralia
| | - Giuseppe Luna
- School of Pharmacy and Biomedical SciencesCurtin UniversityBentleyWestern AustraliaAustralia
| | - Laurens Manning
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
- Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Rosemary Wyber
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
- The George Institute for Global HealthSydneyNew South WalesAustralia
| | - Jonathan R. Carapetis
- Wesfarmers Centre of Vaccines and Infectious DiseasesTelethon Kids InstituteUniversity of Western AustraliaPerthWestern AustraliaAustralia
- Department of Infectious DiseasesPerth Children’s HospitalPerthWestern AustraliaAustralia
| | - Kevin T. Batty
- School of Pharmacy and Biomedical SciencesCurtin UniversityBentleyWestern AustraliaAustralia
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Beaton A, Kamalembo FB, Dale J, Kado JH, Karthikeyan G, Kazi DS, Longenecker CT, Mwangi J, Okello E, Ribeiro ALP, Taubert KA, Watkins DA, Wyber R, Zimmerman M, Carapetis J. The American Heart Association's Call to Action for Reducing the Global Burden of Rheumatic Heart Disease: A Policy Statement From the American Heart Association. Circulation 2020; 142:e358-e368. [PMID: 33070654 DOI: 10.1161/cir.0000000000000922] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rheumatic heart disease (RHD) affects ≈40 million people and claims nearly 300 000 lives each year. The historic passing of a World Health Assembly resolution on RHD in 2018 now mandates a coordinated global response. The American Heart Association is committed to serving as a global champion and leader in RHD care and prevention. Here, we pledge support in 5 key areas: (1) professional healthcare worker education and training, (2) technical support for the implementation of evidence-based strategies for rheumatic fever/RHD prevention, (3) access to essential medications and technologies, (4) research, and (5) advocacy to increase global awareness, resources, and capacity for RHD control. In bolstering the efforts of the American Heart Association to combat RHD, we hope to inspire others to collaborate, communicate, and contribute.
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Zhao C, Li S, Zhang J, Huang Y, Zhang L, Zhao F, Du X, Hou J, Zhang T, Shi C, Wang P, Huo R, Woodman OL, Qin CX, Xu H, Huang L. Current state and future perspective of cardiovascular medicines derived from natural products. Pharmacol Ther 2020; 216:107698. [PMID: 33039419 DOI: 10.1016/j.pharmthera.2020.107698] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
The contribution of natural products (NPs) to cardiovascular medicine has been extensively documented, and many have been used for centuries. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Over the past 40 years, approximately 50% of newly developed cardiovascular drugs were based on NPs, suggesting that NPs provide essential skeletal structures for the discovery of novel medicines. After a period of lower productivity since the 1990s, NPs have recently regained scientific and commercial attention, leveraging the wealth of knowledge provided by multi-omics, combinatorial biosynthesis, synthetic biology, integrative pharmacology, analytical and computational technologies. In addition, as a crucial part of complementary and alternative medicine, Traditional Chinese Medicine has increasingly drawn attention as an important source of NPs for cardiovascular drug discovery. Given their structural diversity and biological activity NPs are one of the most valuable sources of drugs and drug leads. In this review, we briefly described the characteristics and classification of NPs in CVDs. Then, we provide an up to date summary on the therapeutic potential and the underlying mechanisms of action of NPs in CVDs, and the current view and future prospect of developing safer and more effective cardiovascular drugs based on NPs.
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Affiliation(s)
- Chunhui Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Sen Li
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Junhong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yuanyun Huang
- Biology Department, Cornell University, Ithaca, NY 14850, United States of America
| | - Luoqi Zhang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Feng Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Xia Du
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; Shaanxi Academy of Traditional Chinese Medicine, Xi'an 710003, China
| | - Jinli Hou
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Tong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Chenjing Shi
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ping Wang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ruili Huo
- China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Owen L Woodman
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia
| | - Cheng Xue Qin
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia; School of Pharmaceutical Science, Shandong University, Shandong 250100, China; Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong 250100, China.
| | - Haiyu Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China.
| | - Luqi Huang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; China Academy of Chinese Medical Sciences, Beijing 100700, China.
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Marantelli S, Hand R, Carapetis J, Beaton A, Wyber R. Severe adverse events following benzathine penicillin G injection for rheumatic heart disease prophylaxis: cardiac compromise more likely than anaphylaxis. HEART ASIA 2019; 11:e011191. [PMID: 31297163 DOI: 10.1136/heartasia-2019-011191] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 12/07/2022]
Abstract
Objective Secondary prophylaxis through long-term antibiotic administration is essential to prevent the progression of acute rheumatic fever to rheumatic heart disease (RHD). Benzathine penicillin G (BPG) has been shown to be the most efficacious antibiotic for this purpose; however, adverse events associated with BPG administration have been anecdotally reported. This study therefore aimed to collate case reports of adverse events associated with BPG administration for RHD prophylaxis. Study design A literature review was used to explore reported adverse reactions to BPG and inform development of a case report questionnaire. This questionnaire was circulated through professional networks to solicit retrospective reports of adverse events from treating physicians. Returned surveys were tabulated and thematically analysed. Reactions were assessed using the Brighton Collaboration case definition to identity potential anaphylaxis. Results We obtained 10 case reports from various locations, with patients ranging in age from early-teens to adults. All patients had clinical or echocardiogram-obtained evidence of valvular disease. The majority of patients (80%) had received BPG prior to the event with no previous adverse reaction. In eight cases, the reaction was fatal; in one case resuscitation was successful and in one case treatment was not required. Only three cases met Level 1 Brighton criteria consistent with anaphylaxis. Conclusion These results indicate that anaphylaxis is not a major cause of adverse reactions to BPG. An alternative mechanism for sudden death following BPG administration in people with severe RHD is proposed.
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Affiliation(s)
- Shannon Marantelli
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Hand
- Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrea Beaton
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rosemary Wyber
- Telethon Kids Institute, University of Western Australia, Subiaco, Western Australia, Australia.,The George Institute for Global Health, Sydney, New South Wales, Australia
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