Rheumatic fever secondary prevention
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Anthony Gallo, B.S. [4]
Overview
Secondary prevention strategies following rheumatic fever include antibiotic prophylaxis immediately after the antibiotic course in treatment of rheumatic fever. Duration of prophylactic treatment varies with degree of cardiac damage secondary to rheumatic fever.
Secondary Prevention
- Secondary prevention strategies following rheumatic fever include antibiotic prophylaxis immediately after the antibiotic course in treatment of rheumatic fever. Duration of prophylactic treatment varies with degree of cardiac damage secondary to rheumatic fever. If the patient or their household contacts develop streptococcal pharyngitis during the prophylactic period, they should be evaluated and treated promptly.
- Providing prophylactic therapy to individuals who have had rheumatic fever with monthly injections of benzathine penicillin G or oral penicillin V decreases the frequency of recurrent Streptococcus pyogenes infections and recurrent rheumatic fever episodes. It is estimated that the recurrence rate of rheumatic fever is decreased about 85% by providing prophylactic penicillin therapy.
- Alternatives to benzathine penicillin G are available, although they are less effective and require careful monitoring. These include:[1]
| Patient | Alternative Secondary Preventive Thearpy |
|---|---|
| Refuses intramuscular benzathine penicillin G | Oral penicillin |
| Allergic to penicillin | A non beta-lactam antimicrobial (e.g., erythromycin) |
| Pregnant | Penicillin prophylaxis should continue for the duration of pregnancy, as there is no evidence of teratogenicity. Erythromycin is also considered safe in pregnancy. |
| Anticoagulated | Benzathine penicillin G injections should continue unless there is evidence of uncontrolled bleeding, or the international normalized ratio is outside the defined therapeutic window |
- Recurrence of rheumatic fever is higher among patients receiving oral prophylaxis than those receiving intramuscular benzathine penicillin G. This may be attributed to patient compliance.[2]
- Secondary prophylaxis for 1 year among patients with post streptococcal reactive arthritis (PSRA) is recommended.[3][4]
Antimicrobial Regimen
- Secondary prevention of rheumatic fever:[5]
- Preferred regimen (1): Penicillin G benzathine 1.2 MU IM single dose q4w
- Preferred regimen (2): Penicillin V potassium 250 mg PO bid
- Preferred regimen (3): Sulfadiazine 1 g PO qd
- Alternative regimen: Erythromycin 250 mg PO bid
- Note: Duration of secondary prophylaxis for rheumatic fever differs for different scenarios. For rheumatic fever with carditis and residual heart disease (persistent VHD) 10 y or until patient is 40 y of age (whichever is longer). For rheumatic fever with carditis but no residual heart disease (no valvular disease) 10 y or until patient is 21 y of age (whichever is longer). For rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer).
2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [5]
Secondary Prevention (DO NOT EDIT) [5]
| Class I |
|
“1. Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically mitral stenosis (MS).(Level of Evidence: C)” |
References
- ↑ RF/RHD Guideline Development Working Group of the National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand. Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia: an evidence-based review. Sydney (Australia): National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand; 2006 Jun
- ↑ FEINSTEIN AR, WOOD HF, EPSTEIN JA, TARANTA A, SIMPSON R, TURSKY E (1959). “A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis”. N Engl J Med. 260 (14): 697–702. doi:10.1056/NEJM195904022601405. PMID 13644570.
- ↑ Ahmed S, Ayoub EM, Scornik JC, Wang CY, She JX (1998). “Poststreptococcal reactive arthritis: clinical characteristics and association with HLA-DR alleles”. Arthritis Rheum. 41 (6): 1096–102. doi:10.1002/1529-0131(199806)41:6<1096::AID-ART17>3.0.CO;2-Y. PMID 9627020.
- ↑ Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). “Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics”. Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.
- ↑ 5.0 5.1 5.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). “2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines”. J Thorac Cardiovasc Surg. 148 (1): e1–e132. doi:10.1016/j.jtcvs.2014.05.014. PMID 24939033.
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