What is the treatment for acute rheumatic fever?

Treatment of Acute Rheumatic Fever

The primary treatment for acute rheumatic fever is penicillin, with intramuscular benzathine penicillin G being the most effective option to prevent recurrences and progression of rheumatic heart disease. 1

Antibiotic Treatment

First-Line Therapy

• Intramuscular Benzathine Penicillin G (preferred option)
  • Adults: 1,200,000 units as a single deep intramuscular injection 2
  • Older pediatric patients: 900,000 units as a single injection
  • Younger children (<60 lbs): 300,000-600,000 units
  • Advantages: One-time administration ensures compliance, most effective in preventing recurrences 1
  • Administration: Deep intramuscular injection in the upper outer quadrant of buttock or ventrogluteal site
  • Caution: Never inject into or near an artery or nerve, or intravenously 2

Alternative Oral Options

• Penicillin V (if IM injection not feasible)

  • Adults and adolescents: 500 mg 2-3 times daily for 10 days
  • Children: 250 mg 2-3 times daily for 10 days
  • Note: Must complete full 10-day course even if symptoms resolve earlier 1

• Amoxicillin (alternative to Penicillin V)

  • 50 mg/kg once daily (maximum 1000 mg) for 10 days
  • Advantages: Better palatability and once-daily dosing improves compliance 1, 3

For Penicillin-Allergic Patients

• Narrow-spectrum cephalosporins (for non-anaphylactic penicillin allergy)

  • Cefadroxil or cephalexin for 10 days 1

• Clindamycin

  • For patients allergic to both penicillin and cephalosporins
  • Low resistance rates (1%) among Group A Streptococcus 1

• Macrolides (erythromycin, clarithromycin) or azalides (azithromycin)

  • Last resort due to increasing resistance patterns
  • Caution with drug interactions, especially with medications metabolized by cytochrome P-450 3A 1

Anti-inflammatory Treatment

• High-dose aspirin

  • Particularly effective for arthritis symptoms
  • Response is typically prompt and dramatic 4
  • Dosing should be adjusted based on symptom severity

• Corticosteroids

  • Reserved for severe carditis
  • No evidence that they prevent long-term valve damage

Secondary Prophylaxis

Secondary prophylaxis is critical to prevent recurrences and worsening of rheumatic heart disease:

Intramuscular Prophylaxis (Preferred)

• Benzathine Penicillin G
  • 1.2 million units IM every 4 weeks (every 3 weeks in high-risk situations) 1
  • Duration based on disease severity:
    • With carditis and residual heart disease: 10 years or until age 40, whichever is longer
    • With carditis but no residual heart disease: 10 years or until age 21, whichever is longer
    • Without carditis: 5 years or until age 21, whichever is longer 1

Oral Prophylaxis Options

• Penicillin V: 250 mg twice daily
• Sulfadiazine: 1 g once daily (for penicillin-allergic patients)
• Macrolide or azalide antibiotics: For patients allergic to both penicillin and sulfadiazine 1

Monitoring and Follow-up

• Regular echocardiograms to assess for valvular damage
• Specialist cardiac review, especially for those with carditis
• Adherence monitoring for prophylactic treatment (critical as average adherence rates are only about 56%) 5

Important Clinical Considerations

• Patients who develop carditis in their initial attack are at high risk of further cardiac damage with recurrences 6
• Even when started up to 9 days after onset of symptoms, penicillin effectively prevents primary attacks of rheumatic fever 1
• Patients are considered non-contagious after 24 hours of antibiotic therapy 1
• Lifelong prophylaxis may be recommended for high-risk patients, including after valve replacement 1

Common Pitfalls to Avoid

1. Poor adherence to prophylaxis - Consider intramuscular benzathine penicillin G for patients unlikely to complete oral regimens
2. Inadequate duration of prophylaxis - Follow guidelines based on presence/absence of carditis and residual heart disease
3. Misdiagnosis of poststreptococcal reactive arthritis - Observe carefully for carditis development
4. Premature discontinuation of treatment - Complete full 10-day course of antibiotics even if symptoms resolve
5. Inadequate follow-up - Regular monitoring is essential, especially for those with cardiac involvement

Proper treatment and long-term prophylaxis are essential to prevent recurrences and minimize the risk of permanent rheumatic heart disease, which remains a significant cause of morbidity and mortality worldwide 7.