title: Rheumatic fever recurrence prevention: a nurse-led programme of 28-day penicillin in an area of high endemnicity.
abstract: OBJECTIVE
  To evaluate safety and effectiveness of 28-day long-acting penicillin to prevent recurrences of acute rheumatic fever (ARF).
  
  
  METHODS
  Historical cohort study using the regional RF register for Auckland, New Zealand, in a 5-14-year-old population with ARF rates of ~40-80/100,000. Consented patients were referred to a population-based delivery programme of free benzathine penicillin every 28 days by community nurses with discharge after the longer of 10 years of treatment or aged 21 years. First-episode and recurrent ARF cases classified as definite (Jones criteria 1992) or probable (Jones criteria 1956) were the main outcome measures.
  
  
  RESULTS
  Of the 360 cases meeting the case definitions, 20 recurrences occurred in 19 people (median age 21 years). The age at first episode was 2-52 years (mode 11 years), median age 21.3 (8-40). ARF recurred 0-21 years after penicillin was discontinued. Seventy-two per cent of recurrent cases occurred within 5 years, and 12% between 5 years and 10 years. The 4-weekly long-acting penicillin failure rate (n= 1) was 0.07/100 patient years. The programme failure rate (Auckland residents) was 1.4/100 patient years (n= 20). Patient non-adherence accounted for 55% of recurrences. Two recurrences after discharge from prophylaxis as per the New Zealand guidelines occurred 3 years and 13 years later.
  
  
  CONCLUSIONS
  In this environment, 28-day long-acting penicillin prophylaxis for at least 10 years delivered by community nurses is safe and effective for patients with no or mild cardiac disease by auscultation at discharge off penicillin. Penicillin delivery every 21 days (as suggested by a recent Cochrane review) would add to costs and complexity.
authors.affiliation: University of Auckland, Auckland, New Zealand.
authors.forename: Heather
authors.initials: H
authors.lastname: Spinetto
authors.forename: Diana
authors.initials: D
authors.lastname: Lennon
authors.forename: Margaret
authors.initials: M
authors.lastname: Horsburgh
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009520:New Zealand / Q000453:epidemiology; D010406:Penicillins / Q000008:administration & dosage / Q000494:pharmacology / Q000627:therapeutic use*; D012213:Rheumatic Fever / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D013297:Streptococcus pyogenes / Q000187:drug effects; D055815:Young Adult
chemical_list: D010406:Penicillins