To review the literature on dose and regimens of intramuscular benzathine penicillin G (BPG) for secondary prophylaxis of recurrent rheumatic fever.
For over 40 years BPG has been the gold standard for secondary prophylaxis, usually as a dose of 1,200,000 U (900 mg). Although studies have suggested that BPG injections every 3 weeks are superior to injections every 4 weeks, implementation of an every 3 weeks regimen can be problematic with regards to both patient compliance (adherence) and an increased burden on health resources.
Some of the earliest studies of BPG suggested that larger doses resulted in prolongation of detectable penicillin levels. A recent study assessing plasma penicillin levels after BPG doses of 1,200,000 U, 1,800,000 U, and 2,400,000 U suggested there may be benefits in a BPG regimen every 4 weeks with doses higher than the standard 1,200,000 U.
Further studies of higher dose BPG regimens seem justified. In addition, further work is needed on quality and storage options for different BPG preparations; location and method of BPG injections; the importance of weight differences between individuals; and ways of improving access to and compliance with BPG regimens.