CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
124
AFRICA
Benzathine penicillin adherence for secondary
prophylaxis among patients affected with rheumatic
heart disease attending Mulago Hospital
CHARLES MUSOKE, CHARLES KIIZA MONDO, EMMY OKELLO, WANZHU ZHANG, BARBARA KAKANDE,
WILSON NYAKOOJO, JUERGEN FREERS
Abstract
Introduction:
Rheumatic heart disease (RHD) frequently
occurs following recurrent episodes of acute rheumatic fever
(ARF). Benzathine penicillin (benzapen) is the most effec-
tive method for secondary prophylaxis against ARF whose
efficacy largely depends on adherence to treatment. Various
factors determine adherence to therapy but there are no
data regarding current use of benzapen in patients with
RHD attending Mulago Hospital. The study aims were (1)
to determine the levels of adherence with benzapen prophy-
laxis among rheumatic heart disease patients in Mulago
Hospital, and (2) establish the patient factors associated with
adherence and, (3) establish the reasons for missing monthly
benzathine penicillin injections.
Methods:
This was a longitudinal observational study carried
out in Mulago Hospital cardiac clinics over a period of 10
months; 95 consecutive patients who satisfied the inclusion
criteria were recruited over a period of four months and
followed up for six months. Data on demographic character-
istics and disease status were collected by means of a stand-
ardised questionnaire and a card to document the injections
of benzapen received.
Results:
Most participants were female 75 (78.9%). The
age range was five to 55 years, with a mean of 28.1 years
(SD 12.2) and median of 28 years. The highest education
level was primary school for most patients (44, 46.3%)
with eight (8.4%) of the patients being illiterate. Most
were either NYHA stage II (39, 41.1%) or III (32, 33.7%).
Benzathine penicillin adherence: 44 (54%) adhered to the
monthly benzapen prophylaxis, with adherence rates
≥
80%; 38 (46%) patients were classified as non-adherent to
the monthly benzapen, with rates less than 80%. The mean
adherence level was 70.12% (SD 29.25) and the median level
was 83.30%, with a range of 0–100%; 27 (33%) patients had
extremely poor adherence levels of
≤
60%. Factors associated
with adherence: higher education status, residing near health
facility favoured high adherence, while painful injection was
a major reason among poor performers.
Conclusion:
The level of non-adherence was significantly
high (46%). Residence in a town/city and having at least
a secondary level of education was associated with better
adherence, while the painful nature of the benzapen injec-
tions and lack of transport money to travel to the health
centre were the main reasons for non-adherence among RHD
patients in Mulago.
Keywords:
rheumatic heart disease, benzathine penicillin,
secondary prophylaxis, adherence
Submitted 26/4/12, accepted 17/4/13
Cardiovasc
J Afr
2013;
24
: 124–129
DOI: 10.5830/CVJA-2013-022
In developing countries, rheumatic fever (RF) is the predominant
cause of acquired childhood cardiomyopathy.
1,2
The prevalence
of RHD is estimated to be higher in developing than in developed
countries, ranging from 24/1 000 to 0.3/1 000, respectively.
3-5
Rheumatic heart disease might occur following a single episode
of acute rheumatic fever (ARF); however, it is most often the
result of recurrent episodes.
6
Those diagnosed with ARF are at
higher risk of suffering further episodes of ARF than the general
population, with the incidence of rheumatic fever following
streptococcal infection as high as 50% in those with previous
ARF,
7
compared with only 1–3% in the general population.
8
Long-term treatment with penicillin is recommended to
prevent infection with Group A streptococcus among those
with a previous diagnosis of ARF, and it has been shown to
significantly reduce the morbidity and mortality associated with
both recurrent ARF and RHD.
9,10
The severity and prognosis
of RHD depends on the extent of cardiac involvement and
the frequency of recurrent events. Adherence to penicillin
prophylaxis is therefore essential to prevent rapid progression
of disease.
Adherence variability to three- or four-weekly injections of
benzathine penicillin is well documented, both in the community
setting and in hospital-based studies. Several factors could
explain the non-adherence observed among these patients:
intramuscular injections of benzathine penicillin are painful
and may sometimes be associated with allergic reactions.
6
Among asymptomatic or minimally symptomatic patients, this
might prove to be a deterrent, particularly if the links to future
recurrence of rheumatic fever are not repeatedly reiterated.
Furthermore, practitioners in the community might be reluctant
to administer penicillin injections for fear of anaphylaxis.
7
Department of Medicine, College of Health Sciences,
Makerere University, Kampala, Uganda
CHARLES MUSOKE, MB ChB, MMed
CHARLES KIIZA MONDO, MB ChB, MMed, PhD charlesmon-
WANZHU ZHANG, MB ChB, MMed
JUERGEN FREERS, MB ChB, MMed, MD
Uganda Heart Institute, Mulago National Referral Hospital,
Kampala, Uganda
CHARLES KIIZA MONDO, MBChB, MMed, PhD
EMMY OKELLO, MB ChB, MMed
BARBARA KAKANDE, MBChB, MMed
WILSON NYAKOOJO, MB ChB, MMed, MD
