What is the treatment for rheumatic fever?

Treatment of Rheumatic Fever

The treatment of rheumatic fever requires both acute management with anti-inflammatory medications and long-term antibiotic prophylaxis to prevent recurrences and progression to rheumatic heart disease. 1

Acute Treatment Phase

Anti-inflammatory Therapy

• First-line treatment: Aspirin (acetylsalicylic acid) at 75-100 mg/kg/day divided into 4-5 doses for 4-6 weeks 1

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

• For severe carditis, congestive heart failure, or pericarditis: Corticosteroids are preferred over salicylates due to their more potent anti-inflammatory effects 2

Antibiotic Treatment

• Eradication of current Group A Streptococcal (GAS) infection is essential
• First-line: Penicillin (either oral penicillin V or injectable benzathine penicillin G) 3
• For penicillin-allergic patients: Options include:
  • Narrow-spectrum oral cephalosporin (10-day course)
  • Oral clindamycin (20 mg/kg/day in 3 divided doses, max 1.8 g/day for 10 days)
  • Macrolides such as 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) 1

Secondary Prevention

Antibiotic Prophylaxis

• Intramuscular benzathine penicillin G is the most effective regimen for preventing recurrences of rheumatic fever 4, 5

  • Dosage: 1.2 million units IM every 4 weeks (or every 3 weeks in high-risk situations) 3, 6
  • Moderate-certainty evidence shows intramuscular penicillin reduces recurrence risk approximately 10 times better than oral antibiotics 4

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

  • Penicillin V potassium: 250 mg orally twice daily 3
  • Sulfadiazine: 1 g orally once daily 3
  • Macrolide or azalide antibiotics (for patients allergic to both penicillin and sulfadiazine) 3

Duration of Prophylaxis

Based on the American Heart Association recommendations 3, 1:

Clinical Scenario	Duration of Prophylaxis
Rheumatic fever with carditis and residual heart disease (persistent VHD)	10 years or until age 40, whichever is longer (sometimes lifelong)
Rheumatic fever with carditis but no residual heart disease	10 years or until age 21, whichever is longer
Rheumatic fever without carditis	5 years or until age 21, whichever is longer

Important: Secondary prophylaxis is required even after valve replacement 3

Monitoring and Follow-up

• Regular echocardiographic assessment to monitor valvular function and disease progression 1
• Monitoring of acute phase reactants (ESR, CRP) until normalized 1
• Regular cardiac follow-up for patients with rheumatic heart disease 1
• Strict adherence to prophylaxis regimen is critical 1

Special Considerations

Risk Factors for Recurrence

• Multiple previous attacks of rheumatic fever 1
• Increased exposure to streptococcal infections (children, adolescents, teachers, healthcare workers) 1
• Recurrent rheumatic fever is associated with worsening of rheumatic heart disease 3

Important Caveats

• GAS infection does not have to be symptomatic to trigger a recurrence 3
• Rheumatic fever can recur even when symptomatic infections are treated 3
• Development of chronic valvular lesions depends on presence of carditis in previous attacks and compliance with secondary prophylaxis 2
• For severe mitral regurgitation causing intractable heart failure, surgical intervention (valve repair or replacement) may be necessary 2

By following these evidence-based treatment protocols, the risk of recurrent rheumatic fever and progression to rheumatic heart disease can be significantly reduced, improving long-term morbidity and mortality outcomes.