Secondary Prophylaxis for Rheumatic Fever
All patients with a history of rheumatic fever or rheumatic heart disease require long-term antibiotic prophylaxis to prevent recurrent group A streptococcal infections and progression of cardiac damage. 1
First-Line Antibiotic Regimen
Intramuscular benzathine penicillin G (1.2 million units every 4 weeks) is the gold standard and most effective regimen for secondary prophylaxis. 1, 2, 3 This route has the strongest evidence (Class I recommendation) for preventing recurrences compared to oral alternatives. 3, 4
- In high-risk situations (severe cardiac involvement, high streptococcal exposure risk, or history of recurrence), administer benzathine penicillin G every 3 weeks instead of every 4 weeks. 1
- Intramuscular penicillin reduces rheumatic fever recurrence by approximately 90% compared to oral antibiotics (0.1% vs 1% recurrence rate). 4
Alternative Regimens for Penicillin-Allergic Patients
If the patient has documented penicillin allergy, use these alternatives in order of preference: 1, 3
- Oral penicillin V: 250 mg twice daily 1
- Sulfadiazine: 1 g orally once daily (0.5 g once daily if weight ≤27 kg) 1, 3
- Macrolide or azalide antibiotics (erythromycin, clarithromycin, or azithromycin) for patients allergic to both penicillin and sulfadiazine 1
Critical caveat: Macrolide antibiotics must not be used in patients taking cytochrome P450 3A inhibitors (azole antifungals, HIV protease inhibitors, certain SSRIs) due to drug interactions. 1
Duration of Prophylaxis Based on Disease Severity
The duration depends on cardiac involvement and must be calculated from the date of the last rheumatic fever attack: 1
Rheumatic Fever WITH Carditis AND Residual Heart Disease
- Continue for 10 years after last attack OR until age 40, whichever is longer 1, 3
- Consider lifelong prophylaxis if the patient has high-risk features: ongoing high streptococcal exposure (healthcare worker, teacher, military personnel, parent of young children) or severe valvular disease 1
Rheumatic Fever WITH Carditis BUT NO Residual Heart Disease
Rheumatic Fever WITHOUT Carditis
Critical Clinical Considerations
Prophylaxis must continue even after valve replacement surgery because the underlying autoimmune susceptibility persists. 1
Group A streptococcal infections do not need to be symptomatic to trigger rheumatic fever recurrence—at least one-third of recurrences result from asymptomatic infections. 5, 2 This is why continuous prophylaxis is superior to treating only symptomatic pharyngitis. 1
Before initiating long-term prophylaxis, give a full therapeutic course of penicillin to eradicate any residual group A streptococcus, even if the throat culture is negative. 3
Additional Prophylaxis for Dental Procedures
Patients with rheumatic heart disease who are already on continuous penicillin prophylaxis require additional endocarditis prophylaxis with a non-penicillin antibiotic before high-risk dental procedures (gingival manipulation, periapical manipulation, oral mucosa perforation). 3, 6 Use clindamycin or a macrolide instead, as oral streptococci likely have developed penicillin resistance in patients on chronic penicillin. 3, 7
Common Pitfalls to Avoid
Never discontinue prophylaxis prematurely—this is the most common error leading to preventable recurrences and progressive cardiac damage. 2 Calculate duration carefully from the last attack, not the initial diagnosis.
Do not rely on treating symptomatic pharyngitis alone in patients with prior rheumatic fever—continuous prophylaxis is mandatory because asymptomatic infections trigger recurrences. 1, 5
Avoid using the same antibiotic class for both secondary prophylaxis and endocarditis prophylaxis during dental procedures, as resistance develops. 3
Monitor adherence closely, particularly with oral regimens, as intramuscular benzathine penicillin has superior efficacy precisely because it eliminates adherence issues. 8, 4, 9