What is the treatment for acute rheumatic fever?

Treatment of Acute Rheumatic Fever

The treatment of acute rheumatic fever requires both antimicrobial therapy to eradicate Group A Streptococcus and anti-inflammatory therapy to manage symptoms, followed by long-term prophylaxis to prevent recurrences.

Primary Treatment Components

1. Antimicrobial Therapy

Eradication of Group A Streptococcal (GAS) infection is essential, even if throat cultures are negative at the time of diagnosis:

• First-line therapy: Intramuscular benzathine penicillin G as a single injection 1

  • Children ≤27 kg: 600,000 units
  • Children >27 kg, adolescents, and adults: 1,200,000 units

• Alternative oral therapy: 10-day course of penicillin V 1, 2

  • Children: 250 mg 2-3 times daily
  • Adolescents and adults: 500 mg 2-3 times daily

• For penicillin-allergic patients (non-anaphylactic reactions):

  • Narrow-spectrum cephalosporin for 10 days 1
  • Clindamycin 20 mg/kg/day in 3 divided doses (max 1.8 g/day) for 10 days 1, 2
  • Azithromycin 12 mg/kg once daily (max 500 mg) for 5 days 1
  • Clarithromycin 15 mg/kg/day divided twice daily (max 250 mg twice daily) for 10 days 1

2. Anti-inflammatory Therapy

• For rheumatic carditis: Prednisone is indicated for acute rheumatic carditis 3

  • Dosing should be based on severity of inflammation and cardiac involvement

• For arthritis: Salicylates or other NSAIDs until symptoms resolve

  • Continue for 2-3 weeks for arthritis symptoms

3. Supportive Care

• Bed rest for patients with carditis until inflammation subsides
• Cardiac monitoring for patients with severe carditis
• Management of heart failure if present

Secondary Prophylaxis

Secondary prophylaxis is crucial to prevent recurrences and must be initiated immediately after completing the treatment for acute episode:

• Preferred regimen: Intramuscular benzathine penicillin G 1, 4, 5

  • Standard dosing: 1,200,000 units every 4 weeks
  • For high-risk patients or in high-prevalence areas: Every 3 weeks is more effective 1, 4, 6

• Alternative oral regimen: Penicillin V 250 mg twice daily 1, 7

  • Note: Intramuscular regimen is more effective than oral regimen 5

• For penicillin-allergic patients: Sulfadiazine or sulfisoxazole 1

  • ≤27 kg: 500 mg once daily

  • 27 kg: 1 g once daily

Duration of Secondary Prophylaxis

The duration depends on the presence of carditis and residual heart disease:

• With carditis and persistent valvular disease: Continue for 10 years after last episode or until age 40, whichever is longer; consider lifelong prophylaxis for high-risk patients 1

• With carditis but no persistent valvular disease: Continue for 10 years or until age 21, whichever is longer 1

• Without carditis: Continue until age 21 or for 5 years after the last attack, whichever is longer 1

Important Considerations

• Compliance with secondary prophylaxis is critical for preventing recurrences
• Regular cardiac follow-up is essential for patients with rheumatic heart disease
• Studies show that 3-weekly benzathine penicillin G injections are more effective than 4-weekly regimens in preventing recurrences 4, 6, 8
• Serum penicillin levels may fall below protective levels before the fourth week after administration 1, 7

Pitfalls to Avoid

• Inadequate duration of antimicrobial therapy (must complete full course)
• Premature discontinuation of secondary prophylaxis
• Failure to monitor for cardiac complications
• Inadequate patient education about the importance of adherence to prophylaxis
• Overlooking the need for more frequent (3-weekly) prophylaxis in high-risk patients

Regular follow-up is essential to monitor for recurrences, assess cardiac status, and ensure compliance with prophylaxis.