How long is penicillin G (Pen G) prophylaxis recommended for patients with rheumatic heart disease (RHD)?

Duration of Penicillin G Prophylaxis for Rheumatic Heart Disease

For patients with rheumatic heart disease (RHD) and persistent valvular disease, penicillin G prophylaxis should be continued for at least 10 years after the last episode of acute rheumatic fever OR until age 40, whichever is longer, with consideration for lifelong prophylaxis in high-risk patients. 1, 2

Recommended Duration Based on Clinical Presentation

• Rheumatic fever with carditis and residual heart disease (persistent valvular disease):

  • Continue prophylaxis for 10 years after the last attack OR until age 40, whichever is longer 1, 2
  • Lifelong prophylaxis may be recommended for patients at high risk of group A streptococcus exposure 1
  • Secondary prophylaxis is required even after valve replacement 1

• Rheumatic fever with carditis but no residual heart disease:

  • Continue prophylaxis for 10 years after the last attack OR until age 21, whichever is longer 1, 2

• Rheumatic fever without carditis:

  • Continue prophylaxis for 5 years after the last attack OR until age 21, whichever is longer 1, 2

Recommended Prophylactic Regimens

• First-line therapy: Benzathine penicillin G 1.2 million units intramuscularly every 4 weeks 1, 2

  • In high-risk situations or populations, administration every 3 weeks may be recommended 1
  • Evidence shows that 2-weekly or 3-weekly injections may be more effective than 4-weekly injections 3

• Alternative options for penicillin-allergic patients:

  • Penicillin V potassium 250 mg orally twice daily 1, 2
  • Sulfadiazine 1 g orally once daily 1, 2
  • Macrolide or azalide antibiotics (dosage varies) 1, 2

Clinical Considerations

• Intramuscular benzathine penicillin G has the strongest evidence (Class I, LOE A) for preventing recurrences of rheumatic fever 1, 2
• Good adherence to penicillin prophylaxis significantly reduces the odds of acute rheumatic fever recurrence or RHD progression by up to 71% compared to poor adherence 4
• Secondary prophylaxis should continue even after valve surgery, including prosthetic valve replacement 1
• The risk of serious allergic reactions to long-term benzathine penicillin G is low, and the benefits outweigh the risks 1, 5

Endocarditis Prophylaxis Considerations

• Current guidelines no longer recommend routine endocarditis prophylaxis for most patients with RHD 6

• Endocarditis prophylaxis is only recommended for high-risk RHD patients with:

  • Prosthetic cardiac valves or prosthetic material used in valve repair 1, 6
  • Previous history of infective endocarditis 1, 6
  • Cardiac transplant recipients who develop cardiac valvulopathy 6

• For patients already receiving penicillin prophylaxis who require endocarditis prophylaxis for dental procedures, an agent other than penicillin should be used due to potential resistance 2, 6, 7

Common Pitfalls to Avoid

• Discontinuing prophylaxis prematurely, especially in patients with residual valvular disease 1, 2
• Using oral penicillin when intramuscular benzathine penicillin G is more effective in preventing recurrences 3, 8
• Failing to continue prophylaxis after valve replacement surgery 1
• Using penicillin for dental procedure prophylaxis in patients already on penicillin prophylaxis for rheumatic fever 6, 7