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Phenoxymethyl penicillin (penicillin V) is a modified version of
benzylpenicillin that is able to be absorbed orally. Absorption is
variable due to acid effects and the presence of food, so the drug
should be given on an empty stomach. Oral penicillin has a very
nasty taste.
Penicillin is a remarkably safe drug, with few adverse effects.
Because it is excreted largely unchanged in the urine, it should be
administered with caution to the very young and people with
impaired renal function. Hypersensitivity reactions (allergies)
occur in about 0.1 per cent (anaphylaxis) to seven per cent (skin
reactions) of the population. Allergies to penicillin occur where
the degradation products of the drug bind to proteins in the body
and become antigenic. This triggers the immune system to produce
antibodies, and on subsequent exposures an immune response occurs.
When administering the drug at any time, including initially,
adequate precautions should be in place to treat for
hypersensitivity and anaphylaxis. A high index of suspicion should
exist for people with a history of allergy, asthma, hay fever or
urticaria (hives).
Prophylaxis should continue for 10 years, or up to the age of 21 (which ever is the longer period), but for those with evidence of carditis, it should continue to age 30 or possibly for life. (15)
Future priorities
In its 2013 position statement, the World Heart Federation outlined priorities for prevention and control of RHD, aiming to reduce global deaths by 25 per cent by 2015. (4) These include:
1) Register-based control programmes.
2) Global access to penicillin.
3) Support for vaccine research.
4) Establishment of education/training hubs and finding public figures to "champion" RHD prevention.
The prevention of RHD is possible through current methods at a fraction of the cost of treating established disease: globally, implementation of these strategies is patchy and lacks funding. New Zealand is a world leader in the establishment of register-based control programmes, (5,13) but there is still a need for a national register to maintain contact with often highly mobile poorer families as they move around the country. Nurse-led secondary prophylaxis programmes have demonstrated success, (18) while the targeting of schools in high-risk areas for identification of GAS sore throats has increased early detection rates and access to timely treatment, (1) although the role of screening programmes is subject to debate internationally. (5)
Underlying factors that contribute to the spread of GAS in New Zealand are the factors most urgently in need of action: poor health and housing and access to primary health care for vulnerable groups. Increased funding and prioritisation of ARF by the New Zealand Government indicate that policymakers recognise and understand these issues. (1)
Globally, research priorities for ARF include looking at better primary and secondary prophylaxis strategies (and determining their success) and improving adherence to treatment. (5) A better understanding of the pathogenesis of ARF and RHD could lead to better diagnosis and early intervention strategies. Most importantly, research is increasingly focused on developing a vaccine against GAS (see Box 1, p22).
Conclusion
ARF has been all but eliminated in developed nations, except New Zealand and Australia, where the high incidence in Maori, Pacific and Aboriginal populations is a cause for immense concern. Nurses have an increasingly important role in the development and delivery of primary and secondary prevention programmes. Understanding the pathogenesis of this disease can help nurses support public and primary health measures to improve the outcomes of GAS infection in vulnerable communities. *