Secondary Prophylaxis for Children with Tympanostomy Tubes After Acute Rheumatic Fever
A child who had tympanostomy tube placement within one year of an acute rheumatic fever episode must receive continuous secondary prophylaxis with benzathine penicillin G 1,200,000 units intramuscularly every 4 weeks (or 600,000 units for children <27 kg), regardless of the tube placement. 1
Why Continuous Prophylaxis is Non-Negotiable
Recurrent rheumatic fever can occur even when symptomatic group A streptococcal infections are treated optimally, and many triggering infections are completely asymptomatic. 1, 2 This means that episodic treatment of pharyngitis is insufficient—continuous antimicrobial prophylaxis is the only effective strategy. 1
Patients with previous acute rheumatic fever are at extremely high risk for recurrent attacks when group A streptococcal pharyngitis develops, with each recurrence potentially worsening rheumatic heart disease or causing new cardiac manifestations. 1, 2 The presence of tympanostomy tubes does not modify this risk.
A group A streptococcal infection does not need to be symptomatic to trigger a rheumatic fever recurrence. 1, 3 Approximately one-third of acute rheumatic fever cases result from inapparent streptococcal infections where patients never had recognized pharyngitis. 2
The Gold Standard Regimen
Benzathine penicillin G intramuscularly every 4 weeks provides approximately 10 times greater protection than oral antibiotics (0.1% vs 1% recurrence rate; relative risk 0.07,95% CI 0.02-0.26). 3, 4
The standard dose is 1,200,000 units every 4 weeks for children ≥27 kg and 600,000 units every 4 weeks for children <27 kg. 1, 5
For high-risk situations (including children, adolescents, parents of young children, teachers, healthcare workers, or economically disadvantaged populations), consider administering benzathine penicillin G every 3 weeks instead of every 4 weeks. 1, 3
Duration of Prophylaxis Based on Cardiac Involvement
The duration depends entirely on whether carditis occurred during the acute rheumatic fever episode and whether residual valvular disease persists: 1
| Cardiac Status | Duration |
|---|---|
| Rheumatic fever WITHOUT carditis | 5 years or until age 21 (whichever is longer) [1] |
| Rheumatic fever WITH carditis but NO residual valvular disease | 10 years or until age 21 (whichever is longer) [1] |
| Rheumatic fever WITH carditis AND residual valvular disease | 10 years or until age 40 (whichever is longer); often lifelong [1,6] |
Critical Points About Tympanostomy Tubes
Tympanostomy tube placement does not eliminate the need for secondary prophylaxis. The tubes address middle ear disease but provide no protection against group A streptococcal pharyngitis or systemic rheumatic fever recurrence. 1
The timing of tube placement (within one year of acute rheumatic fever) is irrelevant to prophylaxis decisions. Secondary prophylaxis must begin immediately after the acute rheumatic fever diagnosis and continue for the full recommended duration based on cardiac involvement. 1, 2
Prophylactic penicillin should be continued indefinitely after any valve surgery, including prosthetic valve replacement. 6 This applies even if the child eventually requires cardiac surgery for rheumatic heart disease.
Alternative Regimens for Penicillin Allergy
For patients with penicillin allergy, sulfadiazine 1 g orally once daily is the recommended alternative. 1, 3
For patients allergic to both penicillin and sulfadiazine, a macrolide or azalide antibiotic may be used, but these should not be used in patients taking medications that inhibit cytochrome P450 3A (such as azole antifungals, HIV protease inhibitors, or some selective serotonin reuptake inhibitors). 1
Common Pitfalls to Avoid
Do not confuse primary treatment (the initial 10-day penicillin course to eradicate residual streptococcus) with secondary prophylaxis (continuous long-term prevention). 2, 3 Both are required, but they serve different purposes.
Do not discontinue prophylaxis prematurely because the child "hasn't had pharyngitis in a while." The absence of symptomatic infections does not indicate protection—asymptomatic infections can still trigger recurrence. 1, 2
Do not assume oral penicillin is equivalent to intramuscular benzathine penicillin G. Real-world adherence to oral prophylaxis is extremely poor (median 8-10% of days covered over 10 years), rendering it largely ineffective. 7 Intramuscular administration is strongly preferred. 1, 3
Do not forget to screen and treat all household contacts. Throat swab specimens should be obtained from all household contacts of a child with acute rheumatic fever, and any positive contacts should be treated regardless of symptoms. 1, 2, 6