What is the treatment for rheumatic fever?

Treatment of Rheumatic Fever

The treatment of rheumatic fever requires both immediate antibiotic therapy to eradicate Group A Streptococcus (GAS) infection and long-term antibiotic prophylaxis to prevent recurrences, with benzathine penicillin G being the cornerstone of therapy. 1

Acute Treatment

Antibiotic Therapy

• First-line treatment: A full therapeutic course of penicillin to eradicate residual GAS infection, even if throat culture is negative 1

  • Intramuscular benzathine penicillin G: Single dose
    • Adults: 1,200,000 units
    • Older pediatric patients: 900,000 units
    • Children <60 lbs: 300,000-600,000 units 2
  • Oral penicillin V: 250 mg orally 2-3 times daily for 10 days

• For penicillin-allergic patients:

  • Macrolide antibiotics (erythromycin)
  • Sulfadiazine: 1 g orally once daily 1
  • Clindamycin: 20 mg/kg/day in 3 divided doses (max 1.8 g/day) for 10 days 3

Anti-inflammatory Therapy

• Aspirin (acetylsalicylic acid): 75-100 mg/kg/day divided into 4-5 doses for 4-6 weeks 3

  • Monitor for hepatotoxicity and gastric irritation
  • Taper over 2-4 weeks after normalization of acute phase reactants

• Corticosteroids: Consider in severe carditis, although evidence for improved long-term outcomes is limited 4

Secondary Prophylaxis

Secondary prophylaxis is crucial to prevent recurrences and worsening of rheumatic heart disease. Continuous antimicrobial prophylaxis is required rather than just treating acute episodes 1.

Recommended Regimens

• First-line: Benzathine penicillin G, 1.2 million units IM every 4 weeks 1

  • In high-risk populations, administration every 3 weeks is recommended 1

• Alternative oral regimens (for penicillin-allergic patients):

  • Penicillin V potassium: 250 mg orally twice daily 1
  • Sulfadiazine: 1 g orally once daily 1
  • Erythromycin: For patients allergic to both penicillin and sulfadiazine 5

Duration of Prophylaxis

Duration depends on presence of carditis and residual heart disease:

Clinical Scenario	Duration of Prophylaxis
Rheumatic fever with carditis and residual heart disease	10 years after last attack OR until age 40, whichever is longer (sometimes lifelong) [1]
Rheumatic fever with carditis but no residual heart disease	10 years after last attack OR until age 21, whichever is longer [1]
Rheumatic fever without carditis	5 years after last attack OR until age 21, whichever is longer [1]

Special Considerations

• Continued prophylaxis: Should continue even after valve surgery, including prosthetic valve replacement 1

• Family members: Streptococcal infections in family members of patients with rheumatic fever should be treated promptly 1

• High-risk procedures: Patients with rheumatic heart disease require additional antibiotic prophylaxis before high-risk dental or surgical procedures 5

• Monitoring: Regular echocardiographic assessment to monitor valvular function and disease progression 3

Important Caveats

• A GAS infection does not need to be symptomatic to trigger a recurrence 1
• Rheumatic fever recurrence can occur even when a symptomatic infection is treated optimally 1
• Risk of recurrence increases with multiple previous attacks 1
• Individuals with increased exposure to streptococcal infections (children, teachers, healthcare workers) have higher recurrence risk 1
• Benzathine penicillin G must be administered by DEEP INTRAMUSCULAR injection in the upper, outer quadrant of the buttock or ventrogluteal site 2
• Never inject penicillin into or near an artery or nerve, or intravenously 2

Prevention of recurrent rheumatic fever through consistent secondary prophylaxis is the most effective strategy to prevent the development of severe rheumatic heart disease 6.