What is the treatment for acute rheumatic fever?

Treatment of Acute Rheumatic Fever

The treatment of acute rheumatic fever requires both eradication of Group A Streptococcal infection and anti-inflammatory therapy, followed by long-term prophylaxis to prevent recurrences. 1, 2

Antibiotic Treatment for GAS Eradication

First-line therapy:

• Intramuscular benzathine penicillin G (preferred) 1, 2, 3
  • Children ≤27 kg: 600,000 units as a single injection
  • Children >27 kg, adolescents, and adults: 1,200,000 units as a single injection
  • Advantages: Ensures compliance and provides reliable blood levels

Alternative oral therapy (10-day course):

• Penicillin V 1, 2
  • Children: 250 mg 2-3 times daily
  • Adolescents and adults: 500 mg 2-3 times daily

For penicillin-allergic patients:

• Narrow-spectrum oral cephalosporin (if no anaphylactic history) 1, 2
• Clindamycin: 20 mg/kg/day in 3 divided doses (max 1.8 g/day) for 10 days 2
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2
• Clarithromycin: 15 mg/kg/day divided twice daily (max 250 mg twice daily) for 10 days 2

Anti-inflammatory Treatment

For arthritis without carditis:

• Aspirin (acetylsalicylic acid): 75-100 mg/kg/day divided into 4-5 doses for 4-6 weeks 4, 5
  • Monitor for hepatotoxicity, gastric irritation, and salicylism
  • Taper over 2-4 weeks after normalization of acute phase reactants

Alternative anti-inflammatory agents:

• Naproxen: Effective alternative with fewer hepatic side effects than aspirin 6
• Tolmetin: 25 mg/kg/day, shown to be effective for arthritis with fewer side effects than aspirin 4

For carditis:

• Moderate to severe carditis: Prednisone or methylprednisolone 2 mg/kg/day (max 60 mg) for 2-3 weeks, then taper over 2-3 weeks 2
• Mild carditis: Aspirin as above, with close monitoring

Long-term Secondary Prophylaxis

Preferred regimen:

• Benzathine penicillin G: 1,200,000 units IM every 4 weeks 1, 2, 3
  • Consider every 3 weeks in high-risk patients or high-prevalence areas

Alternative oral regimens:

• Penicillin V: 250 mg orally twice daily 1, 2
• Sulfadiazine: 1 g orally once daily (500 mg for patients ≤27 kg) 1, 2
• Macrolide antibiotics: For patients allergic to both penicillin and sulfonamides 1, 2

Duration of prophylaxis:

• With carditis and residual heart disease: 10 years after last episode or until age 40, whichever is longer 1, 2
• With carditis but no residual heart disease: 10 years after last episode or until age 21, whichever is longer 1, 2
• Without carditis: 5 years after last episode or until age 21, whichever is longer 1, 2

Monitoring and Follow-up

• Regular monitoring of acute phase reactants (ESR, CRP) until normalized
• Echocardiography at diagnosis and follow-up to assess cardiac involvement
• Regular cardiac follow-up for patients with rheumatic heart disease
• Strict adherence to prophylaxis regimen

Special Considerations

• Secondary prophylaxis is required even after valve replacement 2
• Treat streptococcal infections promptly in family members of patients with rheumatic fever 1
• For patients requiring surgery, consider alternatives to aspirin (like choline magnesium trisalicylate) to avoid bleeding complications 7

Common Pitfalls to Avoid

• Inadequate duration of antibiotic therapy for GAS eradication
• Premature discontinuation of anti-inflammatory therapy
• Poor compliance with secondary prophylaxis
• Failure to recognize mild carditis
• Inadequate monitoring for medication side effects, especially with high-dose aspirin therapy
• Discontinuing prophylaxis too early, particularly in patients with residual heart disease

Remember that proper treatment and adherence to secondary prophylaxis are critical for preventing recurrences and the development or worsening of rheumatic heart disease.