Does a person with a history of Rheumatic Heart Disease (RHD) require antibiotic prophylaxis for a sore throat with flu-like symptoms?

Antibiotic Management for Sore Throat with Flu-like Symptoms in Patients with Rheumatic Heart Disease

Patients with a history of rheumatic heart disease (RHD) who present with a sore throat accompanied by flu-like symptoms do not require antibiotics unless there is evidence of Group A Streptococcal (GAS) infection, as flu-like symptoms suggest a viral etiology rather than streptococcal pharyngitis. 1, 2

Evaluation of Sore Throat in RHD Patients

• A throat culture or rapid antigen detection test for Group A Streptococcus should be performed to determine if the sore throat is caused by GAS, even in the presence of flu-like symptoms 3
• Flu-like symptoms (fever, myalgia, headache, cough) typically suggest viral etiology rather than streptococcal pharyngitis 1, 3
• Non-GAS pharyngitis (including viral causes) has not been described as a trigger for rheumatic fever recurrence 1

Management Recommendations

If GAS Positive:

• Immediate antibiotic treatment is essential to prevent rheumatic fever recurrence 1, 3
• First-line treatment options:
  • Penicillin V: 250 mg orally twice daily for 10 days 1, 4
  • Benzathine penicillin G: 1.2 million units IM as a single dose 4
• For penicillin-allergic patients:
  • Macrolides (erythromycin or clarithromycin) or azalides (azithromycin) 1, 4
  • Sulfadiazine: 1 g orally once daily for adults 1

If GAS Negative:

• Antibiotics are not indicated for viral pharyngitis 1, 3
• Symptomatic treatment for viral symptoms is appropriate 3

Secondary Prophylaxis for RHD Patients

• All patients with established RHD should already be on continuous antibiotic prophylaxis to prevent recurrent rheumatic fever 1
• The duration of prophylaxis depends on RHD severity 1:
  • Severe RHD: Minimum 10 years after most recent attack or until age 40 (whichever is longer) 1
  • Moderate RHD: Minimum 10 years after most recent attack or until age 35 (whichever is longer) 1
  • Mild RHD: Minimum 5-10 years after most recent attack or until age 21 (whichever is longer) 1

Important Clinical Considerations

• A GAS infection does not have to be symptomatic to trigger a recurrence of rheumatic fever 1
• Rheumatic fever can recur even when symptomatic GAS infection is treated optimally 1, 3
• At least one-third of rheumatic fever cases result from asymptomatic GAS infections 3
• Patients on secondary prophylaxis who require endocarditis prophylaxis for dental procedures should receive an agent other than penicillin, as oral α-hemolytic streptococci are likely to have developed resistance to penicillin 1, 4

Endocarditis Prophylaxis Considerations

• Current guidelines no longer recommend routine endocarditis prophylaxis for all patients with RHD 1
• Endocarditis prophylaxis is indicated only for specific high-risk procedures involving manipulation of gingival tissue or perforation of oral mucosa 1, 2
• Patients already on secondary prophylaxis for RHD generally do not need additional antibiotics for endocarditis prophylaxis 1, 4

Common Pitfalls to Avoid

• Treating all sore throats with antibiotics without confirming GAS infection 1, 3
• Discontinuing secondary prophylaxis too early 2
• Failing to recognize that flu-like symptoms typically indicate viral rather than bacterial etiology 1, 3
• Overlooking the importance of continuous rather than episodic prophylaxis for RHD patients 1, 5