Acute Rheumatic Fever Treatment
Acute rheumatic fever (ARF) treatment includes antibiotics to eradicate residual group A streptococci and anti-inflammatory therapy to relieve inflammation and reduce fever. [1] Antibiotic therapy is recommended regardless of whether pharyngitis was present at diagnosis or whether strep testing is positive at diagnosis. [1]
Antibiotic Eradication of Residual Group A Streptococci
A full course of penicillin should be given to patients with ARF to eradicate residual group A streptococci. [2]
Anti-Inflammatory Therapy for Disease Control
Salicylates and other anti-inflammatory medicines are recommended to relieve inflammation and decrease fever. [1]
Management of Major ARF Manifestations
Treatment of ARF should include management of cardiac failure when necessary. [1]
Secondary Prophylaxis: Core Recommendation
Continuous antimicrobial prophylaxis is recommended to prevent recurrent ARF episodes after well-documented ARF history or evidence of rheumatic heart disease. [2] Secondary prophylaxis should be initiated as soon as ARF or rheumatic heart disease is diagnosed. [2]
Secondary Prophylaxis Drug Selection and Dosing
- Penicillin G benzathine (intramuscular): 600,000 units every 4 weeks for patients weighing ≤27 kg. [2]
- Penicillin G benzathine (intramuscular): 1,200,000 units every 4 weeks for patients weighing >27 kg. [2]
- Penicillin V potassium (oral): 250 mg twice daily. [2]
- Sulfadiazine (oral, for penicillin allergy when appropriate): 0.5 g once daily for patients weighing ≤27 kg. [2]
- Sulfadiazine (oral, for penicillin allergy when appropriate): 1 g once daily for patients weighing >27 kg. [2]
- Macrolide or azalide therapy: used for patients allergic to penicillin and sulfadiazine, with dosing varying by agent. [2]
Secondary Prophylaxis Duration
Secondary prophylaxis duration depends on the presence and severity of carditis and residual valvular disease. [2]
- ARF with carditis and residual heart disease (persistent valvular disease): 10 years or until age 40 years (whichever is longer). [2]
- ARF with carditis but no residual heart disease (no valvular disease): 10 years or until age 21 years (whichever is longer). [2]
- ARF without carditis: 5 years or until age 21 years (whichever is longer). [2] Prophylaxis duration is typically at least until age 21 years. [1]
Secondary Prophylaxis Optimization and Adherence
Penicillin G benzathine injections every 4 weeks are recommended for secondary prevention in most circumstances in the United States. [2] Administration every 3 weeks may be justified in certain high-risk situations because serum drug levels may fall below protective levels before 4 weeks after the initial dose. [2] A 3-week dosing regimen is recommended only for patients with recurrent ARF despite adherence to a 4-week regimen. [2] Oral prophylaxis is associated with higher recurrence risk than injection-based penicillin G benzathine and is more appropriate for lower-risk patients. [2]
Infective Endocarditis Prophylaxis in Rheumatic Heart Disease
American Heart Association guidance no longer recommends bacterial endocarditis prophylaxis in most patients with rheumatic heart disease. [2] Endocarditis prophylaxis exceptions include patients with prosthetic valves or valves repaired with prosthetic material, patients with previous endocarditis, and specific forms of congenital heart disease. [2] Endocarditis prophylaxis is also recommended for cardiac transplant recipients who develop cardiac valvulopathy. [2]