BPG for ARF and RHD video
Video transcript
Speaker 1 Acute rheumatic fever and rheumatic heart disease, referred to as ARF and RHD, disproportionately affects First Nation, Maori and Pasifika people in Queensland. These preventable health conditions are leading causes of heart disease in children and young adults. Fortunately, disease progression and complications can be prevented through comprehensive long term follow up. Secondary prevention for ARF and RHD focuses on the implementation of treatments to prevent repeated group A streptococcal infections, with the goal of averting recurrent episodes of ARF and protecting the heart from damage.
Speaker 1 A key focus of secondary prevention is secondary prophylaxis, which is the consistent and regular long term administration of antibiotics to patients with a history of ARF or RHD. Intramuscular injection of long acting Benzathine benzylpenicillin G, also known as BPG or Bicillin, is the most effective and preferred medication for ARF and RHD prophylaxis, given its long half-life and no development of antibiotic resistance. BPG is more effective at maintaining serum penicillin concentrations than alternative oral penicillin options and requires less frequent administration.
Speaker 1 Oral antibiotics may be considered in patients with severe penicillin allergy, bleeding disorders, severe needle phobia, or persistent refusal of injections. Secondary prophylaxis duration depends on the patient's age, their ARF history and RHD severity, and is often recommended for ten years or more. BPG is to be administered every 21 to 28 days, with patients often starting on a 28-day schedule.
Speaker 1 A 21-day schedule may be considered for patients at high risk, or patients who have had recurrent ARF or RHD progression, despite consistent adherence to their 28 day schedule. Serum levels of penicillin gradually decline after administration and are below therapeutic prophylaxis levels by day 28. It is essential that repeat BPG doses are given no later than 28 days after a previous dose.
Speaker 1 Health clinics are encouraged to nominate staff to manage RHD portfolios and develop a robust and proactive recall process to help patients attend their BPG administration on time or early. Late administration increases the risk of repeated strep A infections and further damage to heart valves. Refer to Australian resources such as the Therapeutic Guidelines and Australian ARF and RHD Guidelines for further information on secondary prophylaxis.
Speaker 2 There are three sites recommended for deep intramuscular injection of BPG. The ventrogluteal muscle is considered the safest injection site with minimal risk of nerve and blood vessel injury. Decreased perceptions of pain are reported by patients, and thinner layers of adipose tissue increase the likelihood of injection into the muscle. The vastus lateralis muscle is recommended for infants and children of walking age and carries a low risk of nerve and blood vessel injury.
Speaker 2 The dorsogluteal muscle may be used if landmarked correctly, however, it is associated with increased risks due to proximity to the sciatic nerve and major blood vessels. Thicker layers of subcutaneous fat increase risk of accidental subcutaneous injection. The deltoid muscle should never be used for BPG due to product volume and viscosity.
Speaker 3 Despite BPG being crucial for prevention, treatment uptake may be poor given the long treatment duration. The injection can be painful if given without adequate pain relief. Poor engagement may be influenced by patients not understanding the disease or treatment relevance and barriers to care, including geographical isolation and cultural disconnection. Patients are more likely to engage in long term treatment when they trust their care team and have their preference on injection sites and distraction methods incorporated.
Speaker 3 Resources that promote patient choice include Bicillin Game Plan, and Boss of my Body. When appropriate, it is crucial to provide culturally competent care that involves staff such as Aboriginal and Torres Strait Islander health workers. The cultural understanding helps to identify barriers to care, provide education, advocate for and reassure patients and their communities.
Speaker 1 Managing pain effectively is essential to maintaining treatment adherence and avoiding trauma, especially for patients with past negative experiences. Physical restraint and forcing injections undermine trust, causing psychological harm and compounding disengagement. Needle phobia may result from repeated painful procedures and if not appropriately managed, will obstruct care. Early utilisation of coping strategies, education and positive interactions with healthcare providers helps to facilitate long term adherence.
Speaker 1 Where possible, prompt attention on arrival to the clinic, avoiding separation from family and community support. Creating a safe, calm environment and taking the time not to rush furthers positive engagement. Combining pharmacological methods with non-pharmacological distraction strategies provide the best results for mitigating perceived pain, anxiety, and discomfort during injection. It is essential to warm BPG to room temperature, position the patient comfortably and inject slowly over 2 to 3 minutes to reduce pain and muscle trauma.
Speaker 1 Pre injection pharmacological options may include oral simple analgesia such as paracetamol or ibuprofen, and application of topical anaesthetic creams prior to injection. For severe pain or phobia the addition of local anaesthetic lidocaine to the injected BPG or use of nitrous oxide for procedural sedation may be appropriate in approved settings.
Speaker 1 Distraction techniques are guided by a patient's age and developmental stage. Options may include videos, music, stories, or blowing bubbles to shift focus, reduce muscle tension and pain perception. Pre injection physical pain reduction techniques may include applying manual pressure with the thumb to injection site or side of palm above the injection site for up to 10 seconds. Ice packs can be applied over injection site for up to five minutes. Sensory signals in the skin can be saturated and pain responses from the body reduced, with devices such as ShotBlocker and Vibrating Buzzy. ShotBlocker should be firmly placed around the injection site with bumps facing down and kept in place while injecting through the U-shaped opening. Vibrating Buzzy with optional cooling pack can be placed directly over the injection site for a minimum of 30 seconds, then moved 2 to 3cm above injection site during injection. Post injection, applying heat packs or coil packs to the site, and encouraging movements and simple oral analgesia, if not previously taken, may further reduce pain.
Speaker 1 Local policies and procedures for safe medication administration, land marking injection sites and adhering to aseptic non-touch techniques must be followed.
Speaker 3 The Extended Practice Authority for Aboriginal and Torres Strait Islander Health practitioners in Queensland provides guidance around health practitioners administering intramuscular BPG in accordance with the local workplace health management practice plans. Presentations for BPG administration provide an opportunity to engage in health checks to identify any additional concerns or missed treatment that require follow up, such as acute strep A infections and concerns with ARF recurrence or RHD progression.
Speaker 2 BPG should only be ceased after review by a medical officer experienced in ARF and RHD. Recommendations include a recent echocardiogram assessing for stable cardiac function and assessment of medical history for ongoing risk of strep eye exposure and disease progression. BPG is considered safe and if previously indicated, it should continue during pregnancy, breastfeeding, and after valve surgery. Unless given within the past seven days, routine secondary prophylaxis administration does not replace the need to treat acute strep A infections. If a BPG dose is administered before the next routinely scheduled dose, such as for an acute strep A infection, the next dose of secondary prophylaxis will reset from that date and be due 21 to 28 days after the additional dose. Regardless of last BPG dose, patients with RHD require antibiotics for infective endocarditis prophylaxis prior to at risk invasive procedures.
Speaker 1 When it comes to BPG or Bicillin for ARF and RHD, key points to remember are BPG is the recommended and preferred medication for secondary prophylaxis to prevent recurrent ARF and RHD progression. BPG is to be given on time or early every 21 to 28 days. Never late. BPG is to be warmed to room temperature before administration and injected slowly over 2 to 3 minutes.
Speaker 1 Pain reduction strategies are crucial steps for positive and therapeutic medication administration. If previously recommended, BPG should continue during pregnancy, breastfeeding and after RHD related heart surgery. And positive, flexible and culturally inclusive patient engagement is essential to maintaining adherence for the long treatment duration of BPG.
Speaker 4 The Queensland RHD Register is a statewide disease register that supports healthcare providers with long term management of patients living with ARF and RHD. The Register relies on timely updates from healthcare providers regarding patient treatment, management and movements to maintain accurate and current patient information. The Register sends recall lists to health services for patients who are due or overdue treatment or review.
Speaker 4 It also sends information to The Viewer allowing healthcare providers timely access to patient information. Information on The Viewer for patients of The Register includes the patient's diagnosis details, care plans, disease severity and secondary prophylaxis, and echocardiogram details. All Queensland Health employees and eligible health practitioners external to Queensland Health can access The Viewer. Useful information and resources can be found on the Queensland Health ARF and RHD web page.