What is the treatment for rheumatic fever?

From the Guidelines

The treatment for rheumatic fever involves a comprehensive approach targeting both the acute infection and preventing long-term complications, with antibiotics being the cornerstone of treatment, specifically penicillin as the first-line therapy to eradicate group A streptococcal infection, as recommended by the most recent guidelines 1. The goal of treatment is to prevent long-term complications, particularly rheumatic heart disease, which can lead to significant morbidity and mortality.

• Antibiotics are used to treat the acute infection, with penicillin being the preferred choice, given its efficacy and narrow spectrum of activity, as noted in earlier guidelines 1.
• For patients with acute rheumatic fever, a 10-day course of oral penicillin V or a single intramuscular injection of benzathine penicillin G is recommended, with alternatives available for penicillin-allergic patients, such as erythromycin, as discussed in previous recommendations 1.
• After the acute phase, long-term prophylaxis with monthly benzathine penicillin G injections or daily oral penicillin V is crucial to prevent recurrence, with the duration of prophylaxis depending on the severity of rheumatic heart disease and the patient's risk factors, as outlined in the most recent systematic review 1.
• The duration of secondary prophylaxis should be at least 10 years after the most recent episode of acute rheumatic fever or until the patient is 40 years old, whichever is longer, for patients with severe rheumatic heart disease, as recommended by the latest guidelines 1.
• Secondary prophylaxis should continue after valve surgery, emphasizing the importance of long-term management to prevent further complications, as highlighted in recent clinical practice guidelines 1.

From the FDA Drug Label

Prevention of Initial Attacks of Rheumatic Fever Penicillin is considered by the American Heart Association to be the drug of choice in the prevention of initial attacks of rheumatic fever (treatment of Streptococcus pyogenes infections of the upper respiratory tract e.g., tonsillitis, or pharyngitis). 1 Erythromycin tablets are indicated for the treatment of penicillin-allergic patients. The therapeutic dose should be administered for ten days. Prevention of Recurrent Attacks of Rheumatic Fever Penicillin or sulfonamides are considered by the American Heart Association to be the drugs of choice in the prevention of recurrent attacks of rheumatic fever In patients who are allergic to penicillin and sulfonamides, oral erythromycin is recommended by the American Heart Association in the long-term prophylaxis of streptococcal pharyngitis (for the prevention of recurrent attacks of rheumatic fever).1

The treatment for rheumatic fever involves the use of penicillin as the drug of choice for the prevention of initial attacks, and penicillin or sulfonamides for the prevention of recurrent attacks. For patients allergic to penicillin, erythromycin is indicated, and for those allergic to both penicillin and sulfonamides, oral erythromycin is recommended for long-term prophylaxis 2.

• Initial attacks: Penicillin is the preferred treatment, with erythromycin as an alternative for penicillin-allergic patients.
• Recurrent attacks: Penicillin or sulfonamides are the preferred treatments, with oral erythromycin as an alternative for patients allergic to both.

From the Research

Treatment for Rheumatic Fever

The treatment for rheumatic fever involves several approaches, including:

• Antibiotic prophylaxis to prevent recurrence of rheumatic fever and progression to rheumatic heart disease 3
• Eradication of streptococcal infection with appropriate antibiotics, such as benzathine penicillin, penicillin V, or azithromycin 4, 5
• Control of inflammatory process with aspirin or steroids 4
• Treatment of cardiac complications, such as valvular heart disease, congestive heart failure, and atrial fibrillation 4
• Secondary prophylaxis with benzathine penicillin to prevent recurrent episodes of rheumatic fever 4, 6, 5

Antibiotic Prophylaxis

Antibiotic prophylaxis is a crucial aspect of rheumatic fever treatment, with studies showing that:

• Long-term antibiotic prophylaxis can reduce the risk of recurrence of rheumatic fever and progression to rheumatic heart disease 3
• Intramuscular penicillin is likely more effective than oral antibiotics in preventing rheumatic fever recurrence and streptococcal throat infections 3, 6
• A 3-week regimen of benzathine penicillin G injections may be more effective than a 4-week regimen in preventing streptococcal infections and rheumatic fever recurrence 7

Secondary Prophylaxis

Secondary prophylaxis is essential for individuals who have had a previous episode of rheumatic fever, with guidelines recommending:

• Continuous antimicrobial prophylaxis to prevent recurrent episodes of rheumatic fever 5
• Penicillin as the agent of choice for secondary prophylaxis, with sulfadiazine or erythromycin as acceptable alternatives in penicillin-allergic individuals 5
• The duration of prophylaxis depending on the number of previous attacks, the time lapsed since the last attack, the risk of exposure to streptococcal infections, the age of the patient, and the presence or absence of cardiac involvement 5