Treatment of Acute Rheumatic Fever
Acute rheumatic fever requires immediate initiation of a full 10-day course of penicillin to eradicate residual group A streptococcus (even if throat culture is negative), followed by continuous long-term antimicrobial prophylaxis with intramuscular benzathine penicillin G to prevent recurrent attacks and progression of rheumatic heart disease. 1
Acute Phase Treatment: Eradication of Streptococcal Infection
First-Line Antibiotic Therapy
All patients diagnosed with acute rheumatic fever must receive a complete therapeutic course of penicillin to eliminate any residual group A streptococcus, regardless of throat culture results at the time of diagnosis. 1
Treatment options for acute eradication:
Oral Penicillin V: 250 mg 2-3 times daily for children <27 kg; 500 mg 2-3 times daily for children ≥27 kg, adolescents, and adults—given for 10 days 2
Intramuscular Benzathine Penicillin G: Single injection of 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 2
Amoxicillin (alternative): 50 mg/kg once daily (maximum 1 g) for 10 days 2
Penicillin-Allergic Patients
For documented penicillin allergy, acceptable alternatives include 2:
- Narrow-spectrum cephalosporin (avoid in type I hypersensitivity): 10-day course
- Clindamycin: 20 mg/kg/day divided in 3 doses (maximum 1.8 g/day) for 10 days
- Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days
- Clarithromycin: 15 mg/kg/day divided twice daily (maximum 250 mg twice daily) for 10 days
Critical caveat: Tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, and older fluoroquinolones should never be used as they do not adequately eradicate group A streptococcus. 2
Secondary Prophylaxis: Prevention of Recurrence
Continuous antimicrobial prophylaxis is the cornerstone of rheumatic fever management and must be initiated immediately upon diagnosis. 2, 1 This is distinct from acute treatment—it prevents recurrent attacks that worsen cardiac damage. 2
Prophylaxis Regimen
Benzathine Penicillin G 1,200,000 units intramuscularly every 4 weeks is the gold standard for secondary prophylaxis. 1, 3 In high-risk situations (severe cardiac involvement, high community streptococcal prevalence), consider every 3 weeks. 1
For penicillin-allergic patients:
- Erythromycin: Oral twice daily (non-severe or immediate hypersensitivity) 3
Evidence supporting intramuscular over oral prophylaxis: Intramuscular benzathine penicillin reduces rheumatic fever recurrence by approximately 10-fold compared to oral antibiotics (0.1% vs 1% recurrence rate). 4 This superiority is likely due to guaranteed compliance with monthly injections versus daily oral medication. 4
Duration of Secondary Prophylaxis
The duration depends on cardiac involvement and must be individualized based on specific criteria: 2
Rheumatic fever WITH carditis AND persistent valvular disease: 10 years or until age 40 (whichever is longer), sometimes lifelong 2
Rheumatic fever WITH carditis but NO residual valvular disease: 10 years or until age 21 (whichever is longer) 2
Rheumatic fever WITHOUT carditis: 5 years or until age 21 (whichever is longer) 2
Additional risk factors requiring extended prophylaxis: 2
- Multiple previous attacks
- High exposure risk (teachers, healthcare workers, parents of young children, crowded living conditions)
- Economically disadvantaged populations
- Family members with current or previous rheumatic fever
Symptomatic Management
While antibiotics address the underlying streptococcal trigger, symptomatic treatment focuses on reducing inflammation and cardiac complications. 3, 5
Anti-inflammatory therapy (typically salicylates or corticosteroids for severe carditis) is used to relieve symptoms and potentially mitigate cardiac valve damage, though this should be guided by cardiology consultation. 3, 5
Critical Clinical Pearls
Patients become non-contagious after 24 hours of antibiotic therapy. 1, 6
Treatment can effectively prevent rheumatic fever when started up to 9 days after symptom onset, allowing time for proper diagnosis without compromising prevention efficacy. 1, 6
Warming benzathine penicillin G to room temperature before administration reduces injection discomfort. 1
Family members of patients with acute rheumatic fever who develop streptococcal pharyngitis should be treated promptly to prevent transmission and potential rheumatic fever development. 2
Common Pitfalls to Avoid
Never discontinue antibiotics before completing the full 10-day course, even if symptoms resolve earlier—incomplete treatment increases recurrence risk. 2
Do not rely on throat culture results at the time of rheumatic fever diagnosis to determine whether to treat—always give the full eradication course regardless of culture status. 1
Avoid broad-spectrum antibiotics (third-generation cephalosporins, fluoroquinolones) as they are more expensive, promote resistance, and offer no advantage over penicillin. 1
Secondary prophylaxis is not optional—patients with previous rheumatic fever have extremely high risk of recurrence (which worsens cardiac disease), and prophylaxis reduces this risk substantially. 4, 7
Monthly intramuscular penicillin represents secondary prophylaxis to prevent recurrent attacks, not treatment of the acute symptomatic episode—both acute treatment and long-term prophylaxis are required. 1