What is the treatment for a child diagnosed with rheumatic fever?

Treatment of Rheumatic Fever in Children

The treatment of rheumatic fever in children requires a 10-day course of penicillin, with oral penicillin V or intramuscular benzathine penicillin G being the first-line treatments to prevent cardiac complications and recurrence. 1

Primary Antibiotic Treatment Options

First-Line Therapy

• Oral Penicillin V: 250 mg twice daily for 10 days for most children; for children weighing >27 kg (60 lb), adolescents, and adults: 500 mg 2-3 times daily for 10 days 1
• Oral Amoxicillin: 50 mg/kg once daily (maximum 1 g) for 10 days - more palatable than penicillin V and may enhance adherence due to once-daily dosing 1, 2
• Intramuscular Benzathine Penicillin G: Single injection of 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 1

For Penicillin-Allergic Patients

• Narrow-spectrum oral cephalosporins (e.g., cefadroxil, cephalexin) for 10 days - not for patients with immediate (anaphylactic-type) hypersensitivity to penicillin 1
• Oral Clindamycin: 20 mg/kg/day divided in 3 doses (maximum 1.8 g/day) for 10 days 1
• Oral Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
• Oral Clarithromycin: 15 mg/kg/day divided twice daily (maximum 250 mg twice daily) for 10 days 1

Selection Criteria for Treatment Approach

• Intramuscular benzathine penicillin G should be strongly considered for: 1

  • Patients unlikely to complete a 10-day oral course
  • Patients with personal or family histories of rheumatic fever or rheumatic heart disease
  • Patients with environmental risk factors (crowded living conditions, low socioeconomic status)

• Oral therapy may be appropriate when: 1

  • Good compliance can be assured
  • Follow-up is reliable
  • Patient/family preference for oral medication exists

Important Clinical Considerations

• Duration: All patients should complete the full 10-day course of antibiotics, even if symptoms resolve earlier, to prevent rheumatic fever 2
• Timing: Treatment can be effective in preventing rheumatic fever even when started up to 9 days after symptom onset 1
• Contagiousness: Patients are considered non-contagious after 24 hours of antibiotic therapy 1
• Administration tips: For intramuscular injections, warming benzathine penicillin G to room temperature before administration reduces discomfort 1

Anti-inflammatory Treatment

• Aspirin with or without steroids for a total duration of 12 weeks to control the inflammatory process 3
• Treatment of chorea should continue for 2-3 weeks after clinical improvement 3

Secondary Prevention

• After an episode of rheumatic fever, continuous antimicrobial prophylaxis is required to prevent recurrences 1, 4
• Intramuscular benzathine penicillin is superior to oral antibiotics for secondary prevention (approximately 10 times more effective) 4

Common Pitfalls and Caveats

• Undertreatment: Failure to complete the full 10-day course of antibiotics significantly increases the risk of rheumatic fever 2
• Misdiagnosis: Group A streptococcal pharyngitis often cannot be reliably distinguished from viral pharyngitis on clinical grounds alone; laboratory confirmation is important 5
• Inappropriate antibiotic selection: Broad-spectrum cephalosporins are more expensive and more likely to select for resistant flora than narrow-spectrum agents 1
• Inadequate follow-up: In areas where rheumatic fever is prevalent, particularly in underserved populations, intramuscular penicillin is preferred due to guaranteed compliance 6

Monitoring and Follow-up

• Clinical and/or bacteriological follow-up may be necessary for several months after treatment 2
• Patients should be monitored for development of cardiac complications 3

Remember that proper treatment of streptococcal pharyngitis is critical for preventing the initial attack of rheumatic fever, which carries significant risk of cardiac complications and mortality 7.