Benzathine penicillin in the management of the treponematoses

Daily penicillin serum concentrations following injection of 1.2 mega-units of "all-purpose" penicillin

In view of evidence suggesting that 1.2 mega-units of "all-purpose" penicillin (300 000 IU potassium penicillin G, 300 000 IU procaine penicillin G and 600 000 IU benzathine penicillin) did not maintain treponemicidal serum concentrations during the week following injection-which if true, might necessitate a reappraisal of prophylactic and treatment schedules in wide use against syphilis-daily assays were performed to determine the penicillinaemia levels in ambulant adult males for one week following intramuscular injection with this dosage of two "all-purpose" products (168 assays in all, 24 each day).Statistical evaluation of the results showed that the mean daily serum concentrations were, in fact, treponemicidal during the whole week after injection. The means of groups of 24 assays fell within narrow daily ranges on each of the seven post-injection days, suggesting that the long-acting component (benzathine penicillin) gives reliable and predictable daily levels in a high proportion of cases. This is in contrast to those penicillins which rely for their long-acting property on the oily gel in which they are suspended. On the other hand, the extremes of penicillinaemia for any individual in a large group were shown to cover a very wide range, demonstrating that a particular patient's failure to respond to standard treatment or prophylaxis can be due to factors quite unrelated to the quality or specificity of the product or to the sensitivity of the organism causing disease.

Untoward penicillin reactions

The literature on untoward reactions following the administration of penicillin is reviewed. These reactions, including a certain number of deaths which have been reported, are of particular interest to health administrations and to WHO in view of the large-scale programmes for controlling the treponematoses which are now under way-programmes affecting millions of people in many parts of the world.The most serious problems are anaphylactic sensitivity phenomena and superinfection or cross-infection with penicillin-resistant organisms, and the reactions involved range in intensity from the mildest to the fatal; the incidence of the latter is estimated at 0.1-0.3 per million injections. The authors point out that with increasing use of penicillin, more persons are likely to become sensitized and the number of reactions can therefore be expected to rise. The best prevention against such an increase is the restriction of the unnecessary use of penicillin.

Clinical problems in the antibiotic treatment of gonorrhoea

After briefly reviewing the history of penicillin therapy in gonorrhoea, the author shows that the number of cures effected with the repository penicillins, although originally very high, has diminished considerably in recent years, despite a general tendency to increase the dosage. The reduced efficacy of PAM and benzathine penicillin is demonstrated by an exposition of the current results obtained with these two preparations in the treatment of gonorrhoea patients in London. Some of the difficulties involved in distinguishing between treatment failures and reinfections are discussed.The paper continues with an examination of the possible alternatives to repository penicillin in the treatment of gonorrhoea. Data are given on the comparative efficacy of a number of prepations, including mixed penicillins, phenoxymethyl penicillin and various other antibiotics, such as streptomycin and the tetracycline group.The problem of re-examination of treated gonorrhoea cases is also dealt with, practical reasons being given for restricting the period of follow-up to three weeks.Finally, in a discussion of possible future developments, the author suggests a number of measures designed to prevent a further loss of sensitivity to penicillin in the gonococcus.

Prevention of venereal infections

In the first part of this paper, a plea is made for a broad view by health administrations of the preventive aspects of venereal disease control, based on epidemiological rather than purely clinical grounds. Stress is laid on the importance of measures directed towards health promotion, specific protection, early recognition and prompt treatment, disability limitation, and rehabilitation. The value of case-finding and contact-tracing and of systematic blood-testing of certain population groups is emphasized.In the second part, measures for local and systemic prophylaxis are discussed. It is also pointed out that in the past 15 years there has been a rapid reduction in syphilis throughout the world as a whole (although some recrudescence has recently been reported in certain countries), but that over the same period the reservoir of gonorrhoea has been but slightly reduced. The possible epidemiological, immunological and other reasons for this phenomenon are gone into, and the conclusion is reached that the outlook for the control of gonorrhoea is now somewhat less favourable than it was a few years ago. Should apprehension on this score bring about a general orientation away from penicillin (particularly the long-acting preparations) in treating gonorrhoea, the effect on the reservoir of syphilis may also be unfortunate.