What routine management and prophylaxis are recommended for a patient with a history of rheumatic fever?

Routine Management for Patients with a History of Rheumatic Fever

For patients with a history of rheumatic fever, secondary antibiotic prophylaxis is essential and should be administered according to specific guidelines based on the presence or absence of carditis and residual heart disease.

Secondary Prophylaxis Regimens

The cornerstone of management for patients with previous rheumatic fever is secondary antibiotic prophylaxis to prevent recurrent episodes:

• Intramuscular benzathine penicillin G (1.2 million units every 4 weeks) is the first-line prophylactic regimen with the strongest evidence for preventing recurrences 1, 2
• For patients allergic to penicillin, alternatives include:
  • Penicillin V potassium (250 mg orally twice daily) 1
  • Sulfadiazine (1 g orally once daily) 1
  • Macrolide or azalide antibiotics (for those allergic to both penicillin and sulfadiazine) 1, 3

Duration of Prophylaxis

The duration of prophylaxis depends on whether residual heart damage is present:

• For patients with 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
  • Lifelong prophylaxis may be recommended for patients at high risk of group A streptococcus exposure (e.g., teachers, healthcare workers) 1
  • Secondary prophylaxis is required even after valve replacement 1

• For patients with 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

• For patients with rheumatic fever without carditis:

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

Initial Management

• A full therapeutic course of penicillin should first be given to patients with acute rheumatic fever to eradicate residual Group A Streptococcus, even if throat culture is negative 1, 4
• Streptococcal infections in family members of patients with current or previous rheumatic fever should be treated promptly 1

Endocarditis Prophylaxis Considerations

Current guidelines recommend antibiotic prophylaxis before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of oral mucosa only for patients with:

• Prosthetic cardiac valves or prosthetic material used for valve repair 1
• Previous infective endocarditis 1
• Unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation 1
• Cardiac transplant with valve regurgitation 1

Important Clinical Considerations

• Recurrent rheumatic fever is associated with worsening of rheumatic heart disease 1
• Group A streptococcus infection does not have to be symptomatic to trigger a recurrence, and rheumatic fever can recur even when symptomatic infection is treated 1, 4
• Prevention requires continuous antimicrobial prophylaxis rather than recognition and treatment of acute episodes of streptococcal pharyngitis 1, 4
• For patients receiving penicillin prophylaxis who require endocarditis prophylaxis for dental procedures, an agent other than penicillin should be used, as oral α-hemolytic streptococci may have developed resistance to penicillin 2
• Intramuscular penicillin is more effective than oral penicillin in preventing rheumatic fever recurrence and streptococcal throat infections 5, 6

Monitoring and Follow-up

• Regular clinical evaluation for signs of valvular disease progression 1
• Echocardiographic assessment to monitor for development or progression of rheumatic heart disease 1, 6
• Influenza and pneumococcal vaccinations should follow standard recommendations for patients with valvular heart disease 1
• Maintain optimal oral health as an important component of overall healthcare 1, 2

Adherence Considerations

• Register/recall systems and dedicated health teams can improve delivery of secondary antibiotic prophylaxis 7
• Education about rheumatic fever and rheumatic heart disease is important for patient compliance 7
• Strong staff-patient relationships may improve adherence to prophylaxis regimens 7