What is the treatment for rheumatic fever?

Treatment of Rheumatic Fever

Patients with acute rheumatic fever must receive a full 10-day course of penicillin to eradicate residual Group A Streptococcus (GAS), followed immediately by continuous antimicrobial prophylaxis with intramuscular benzathine penicillin G 1.2 million units every 4 weeks (or every 3 weeks in high-risk situations) to prevent recurrent attacks. 1, 2, 3

Acute Phase Treatment: Eradication of GAS

The initial treatment priority is complete eradication of streptococcal infection, even if throat culture is negative at diagnosis. 4, 1, 2

First-line antibiotic options:

• Oral Penicillin V: 250 mg twice daily for 10 days (children <27 kg); 500 mg 2-3 times daily for 10 days (adolescents/adults or children ≥27 kg) 1, 2
• Intramuscular Benzathine Penicillin G: Single injection of 600,000 units (<27 kg) or 1,200,000 units (≥27 kg) 2

For penicillin-allergic patients:

• Erythromycin or first-generation cephalosporins (if no immediate-type hypersensitivity) 1, 3, 5

Important caveat: Treatment can be delayed up to 9 days after symptom onset and still effectively prevent rheumatic fever, allowing time for laboratory confirmation. 4, 2 However, once rheumatic fever is diagnosed, immediate treatment is essential. 4, 1

Secondary Prophylaxis: Prevention of Recurrence

Continuous antimicrobial prophylaxis is the cornerstone of rheumatic fever management and must be initiated immediately upon diagnosis. 4, 1, 3 This is critical because recurrent attacks worsen cardiac damage, and even asymptomatic GAS infections can trigger recurrence. 4, 3

Preferred regimen:

• Benzathine Penicillin G: 1,200,000 units intramuscularly every 4 weeks 1, 3, 6
• In high-risk populations or patients with recurrences despite adherence, consider every 3 weeks 3, 7

Evidence supporting intramuscular over oral: Intramuscular benzathine penicillin is approximately 10 times more effective than oral antibiotics at preventing rheumatic fever recurrence (0.1% vs 1% recurrence rate). 7, 8 This superiority is attributed to guaranteed compliance and sustained therapeutic levels. 8

Alternative for penicillin-allergic patients:

• Erythromycin orally twice daily 5, 6, 9

Practical tip: Warming benzathine penicillin G to room temperature before administration reduces injection discomfort. 2

Duration of Prophylaxis

The duration depends on cardiac involvement and must be individualized based on specific criteria: 4, 1, 3

• Rheumatic fever with carditis AND residual heart disease (persistent valvular disease): 10 years after last attack OR until age 40 (whichever is longer), sometimes lifelong 4, 1, 3
• Rheumatic fever with carditis but NO residual heart disease: 10 years OR until age 21 (whichever is longer) 4, 1, 3
• Rheumatic fever without carditis: 5 years OR until age 21 (whichever is longer) 4, 1, 3

Critical consideration: Prophylaxis should continue even after valve surgery, including prosthetic valve replacement. 3

Anti-Inflammatory Treatment for Symptom Relief

While antibiotics address the underlying infection and prevent recurrence, anti-inflammatory agents provide symptomatic relief but do NOT prevent rheumatic heart disease. 10

For severe inflammation or cardiac involvement:

• Corticosteroids (prednisone 1-2 mg/kg/day for 1-2 weeks) may be considered 3
• In severe cases with significant cardiac involvement, intravenous methylprednisolone (1000 mg/day initially) followed by oral prednisone 3

Special Populations and Situations

Family members: Streptococcal infections in family members of patients with current or previous rheumatic fever should be treated promptly to prevent transmission. 4, 3

Patients with rheumatic heart disease undergoing procedures: Those receiving benzathine penicillin prophylaxis still require amoxicillin prophylaxis before high-risk dental or surgical procedures. If recently treated with penicillin/amoxicillin or have immediate penicillin hypersensitivity, use clindamycin. 6

Obstetric considerations: Pregnant women should not receive erythromycin estolate due to risk of cholestatic hepatitis. 4

Common Pitfalls to Avoid

• Inadequate duration of initial treatment: The full 10-day course is essential even if symptoms resolve earlier. 1, 2
• Failure to initiate secondary prophylaxis immediately: At least one-third of rheumatic fever cases result from asymptomatic GAS infections, making continuous prophylaxis essential rather than episodic treatment. 1, 3
• Premature discontinuation of prophylaxis: Even with optimal treatment, rheumatic fever can recur in susceptible individuals, necessitating adherence to duration guidelines. 1, 3
• Using broad-spectrum antibiotics: These are more expensive and promote resistant flora compared to narrow-spectrum penicillin. 2
• Assuming oral compliance: Intramuscular benzathine penicillin should be strongly considered for patients unlikely to complete oral courses, those with personal/family history of rheumatic fever, or those with environmental risk factors. 2