Treatment of Rheumatic Fever
The treatment of rheumatic fever requires a dual approach: eradication of Group A Streptococcal infection with antibiotics and anti-inflammatory therapy for symptom management, followed by long-term prophylaxis to prevent recurrences. 1
Antibiotic Therapy for Acute Infection
First-Line Treatment
- Intramuscular benzathine penicillin G is the preferred treatment 1:
- 600,000 units for patients ≤27 kg
- 1,200,000 units for patients >27 kg, adolescents, and adults
- Advantages: ensures compliance and provides reliable blood levels
Alternative Antibiotic Options
Oral penicillin V 1:
- 250 mg 2-3 times daily for children
- 500 mg 2-3 times daily for adolescents and adults
- Duration: 10 days
For penicillin-allergic patients 1, 2:
- Erythromycin: Recommended by the American Heart Association for penicillin-allergic patients
- Sulfadiazine: 0.5 g once daily for patients ≤27 kg; 1 g once daily for patients >27 kg
- Macrolides: Azithromycin (12 mg/kg once daily, max 500 mg, for 5 days) or clarithromycin (15 mg/kg/day divided twice daily, max 250 mg twice daily, for 10 days)
- Clindamycin: 20 mg/kg/day in 3 divided doses (max 1.8 g/day) for 10 days
Anti-Inflammatory Therapy
Aspirin (acetylsalicylic acid) 1:
- Dosage: 75-100 mg/kg/day divided into 4-5 doses
- Duration: 4-6 weeks
- Taper over 2-4 weeks after normalization of acute phase reactants
- Monitor for: hepatotoxicity, gastric irritation, and salicylism
Corticosteroids:
- Reserved for severe carditis
- Prednisone: typically 1-2 mg/kg/day (maximum 60 mg/day)
- Duration: 2-3 weeks with gradual tapering
Secondary Prophylaxis
Secondary prophylaxis is critical to prevent recurrences of rheumatic fever and progression of rheumatic heart disease 3, 1, 4.
Preferred Regimen
- Intramuscular benzathine penicillin G 1:
- Every 4 weeks (consider every 3 weeks in high-risk patients or high-prevalence areas)
- Most effective option with approximately 10 times better protection than oral antibiotics 4
Alternative Regimens
- Oral penicillin V: 250 mg orally twice daily 1
- Sulfadiazine: 1 g orally once daily (500 mg for patients ≤27 kg) 1
- Erythromycin: For patients allergic to both penicillin and sulfonamides 2
Duration of Prophylaxis
Duration depends on presence of carditis and residual heart disease 3, 1:
| Clinical Scenario | Duration of Prophylaxis |
|---|---|
| With carditis and persistent valvular disease | 10 years after last episode or until age 40, whichever is longer (sometimes lifelong) |
| With carditis but no persistent valvular disease | 10 years after last episode or until age 21, whichever is longer |
| Without carditis | 5 years after last episode or until age 21, whichever is longer |
Monitoring and Follow-Up
- Regular monitoring of acute phase reactants (ESR, CRP) until normalized 1
- Echocardiography at diagnosis and follow-up to assess cardiac involvement 1
- Regular cardiac follow-up for patients with rheumatic heart disease 1
- Strict adherence to prophylaxis regimen is critical for preventing recurrences 1
Special Considerations
- Treatment can be safely postponed for up to 9 days after symptom onset and still prevent acute rheumatic fever 3
- Secondary prophylaxis is required even after valve replacement 1
- Moderate-certainty evidence shows that antibiotic prophylaxis likely reduces the risk of recurrence of rheumatic fever compared to no antibiotics 4
- People with early or mild rheumatic heart disease likely have the greatest capacity to benefit from prophylaxis 4
Common Pitfalls to Avoid
Inadequate duration of antibiotic therapy: Shortening the course of penicillin by even a few days can result in an appreciable increase in treatment failure rate 3
Poor adherence to secondary prophylaxis: This is the most common reason for recurrence of rheumatic fever 1
Failure to recognize carriers: Chronic streptococcal carriers usually do not need to be identified or treated with antibiotics unless they develop symptomatic infections 3
Inappropriate antibiotic selection: Tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, and fluoroquinolones should not be used to treat Group A streptococcal infections 3
Unnecessary post-treatment throat cultures: These are indicated only in patients who remain symptomatic, whose symptoms recur, or who have had rheumatic fever and are at unusually high risk for recurrence 3