What is the recommended treatment for an adult patient with rheumatic fever?

Treatment of Acute Rheumatic Fever in Adults

For adults with acute rheumatic fever, administer a full 10-day course of penicillin to eradicate Group A Streptococcus, immediately initiate long-term secondary prophylaxis with intramuscular benzathine penicillin G 1.2 million units every 4 weeks, and provide anti-inflammatory therapy for symptom control. 1, 2

Acute Phase Treatment

Antimicrobial Eradication

• Give a complete therapeutic course of penicillin to eliminate residual Group A Streptococcus, even if the throat culture is negative at diagnosis 1, 2
• Penicillin V 500 mg orally 2-3 times daily for 10 days is the standard regimen for adults 3, 1
• For penicillin-allergic patients, use erythromycin or first-generation cephalosporins (avoid cephalosporins if immediate-type hypersensitivity to penicillin exists) 1
• Azithromycin 500 mg once daily for 5 days or clarithromycin 250 mg twice daily for 10 days are acceptable alternatives for penicillin allergy 3

Anti-Inflammatory Therapy

• For severe inflammation or cardiac involvement, consider prednisone 1-2 mg/kg/day for 1-2 weeks 1
• In cases with significant pericarditis or severe cardiac manifestations, intravenous methylprednisolone 1000 mg/day initially may be warranted, followed by oral prednisone 1
• Anti-inflammatory agents provide symptomatic relief but do not prevent progression to rheumatic heart disease 4

Secondary Prophylaxis (Critical for Preventing Recurrence)

Preferred Regimen

• Benzathine penicillin G 1.2 million units intramuscularly every 4 weeks is the gold standard and approximately 10 times more effective than oral antibiotics (0.1% vs 1% recurrence rate) 3, 2, 5
• In high-risk populations or patients with recurrence despite adherence to the 4-week regimen, administer every 3 weeks 3, 1, 2
• Intramuscular penicillin likely reduces rheumatic fever recurrence substantially compared to oral antibiotics (RR 0.07,95% CI 0.02 to 0.26) 5

Alternative Oral Regimens (Only if IM Penicillin Not Feasible)

• Penicillin V 250 mg orally twice daily 3, 2
• Sulfadiazine 1 g orally once daily (for adults) 3, 2
• For patients allergic to both penicillin and sulfadiazine: erythromycin 250 mg orally twice daily 6, 7
• Oral prophylaxis depends heavily on patient compliance and carries higher recurrence risk 6, 8

Duration of Secondary Prophylaxis for Adults

• For adults with rheumatic carditis and residual heart disease (persistent valvular disease): Continue for at least 10 years after the last attack OR until age 40 years (whichever is longer), often lifelong 3, 1, 2
• For rheumatic carditis without residual heart disease: 10 years or until age 21 (whichever is longer) 3, 2
• For rheumatic fever without carditis: 5 years or until age 21 (whichever is longer) 3, 2
• Prophylaxis should continue even after valve surgery, including prosthetic valve replacement 1, 2

Critical Caveats and Pitfalls

Common Mistakes to Avoid

• Do not stop prophylaxis prematurely - recurrent rheumatic fever worsens cardiac damage and at least one-third of cases result from asymptomatic streptococcal infections 3, 1, 2
• Do not use erythromycin as first-line prophylaxis when penicillin or sulfadiazine can be used - it is reserved only for patients with dual allergies 6
• Do not prescribe macrolides with cytochrome P450 3A inhibitors (azole antifungals, HIV protease inhibitors, some SSRIs) due to QT prolongation risk 3, 6
• Even optimal treatment of streptococcal pharyngitis cannot completely prevent rheumatic fever in susceptible individuals 1, 2

Special Considerations

• Adults at high risk for recurrence include those with multiple previous attacks, recent last attack, high streptococcal exposure (healthcare workers, teachers, parents of young children, military personnel), and economically disadvantaged populations 2
• For endocarditis prophylaxis before dental procedures in patients already receiving penicillin prophylaxis for rheumatic fever, use an alternative agent (not penicillin) due to potential oral streptococcal resistance 2, 8
• Patients with rheumatic heart disease receiving benzathine penicillin G should receive amoxicillin prophylaxis before high-risk dental or surgical procedures; if recently treated with penicillin/amoxicillin or penicillin-allergic, use clindamycin 8

Monitoring Requirements

• Initiate continuous antimicrobial prophylaxis as soon as acute rheumatic fever is diagnosed 1, 2
• Family members of patients with rheumatic fever should receive prompt treatment for any streptococcal infections 1
• The risk of recurrence decreases with increasing interval since the last attack but increases with multiple previous episodes 2