Rheumatic fever secondary prevention
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]
Overview
In order to prevent recurrent development of rheumatic fever, an antibiotic prophylaxis should be initiated immediately after the antibiotic course in treatment of rheumatic fever. Duration of prophylactic treatment varies with degree of cardiac damage secondary to rheumatic fever.
Secondary Prevention
If an individual does not contract a Streptococcus pyogenes infection for a long period, perhaps for five years or longer, an individual's immunological/autoimmunological responsivness will naturally decrease and, perhaps, there will be less chance of developing rheumatic fever if the individual contracts a future Streptococcus pyogenes infection.
Prophylactic antibiotic therapy should be initiated immediately after the therapeutic antibiotic course. If the patient or their household contacts develop streptococcal pharyngitis during the prophylactic period, they should be evaluated and treated promptly.
Providing prophylactic therapy to individuals who have had rheumatic fever with monthly (or maybe every three weeks) injections of Benzathine Penicillin G, 1,200,000 units, or oral penicillin V or G, 250mg twice daily (I think 500 mg twice daily is more efficacious), decreases the frequency of recurrent Streptococcus pyogenes infections and therefore recurrent rheumatic fever episodes. It is estimated that the recurrence rate of rheumatic fever is decreased about 85% by providing prophylactic penicillin therapy.
| Agent | Dosage | Mode | Rating |
|---|---|---|---|
| Benzathine penicillin G | 1,200,000 Units every 4 weeks (every 3 weeks for high-risk patients such as those with residual carditis) | Intramuscular | Class I, LOE A |
| or | |||
| Penicillin V | 250 mg twice daily | Oral | Class I, LOE B |
| or | |||
| Sulfadiazine | 0.5 g once daily for patients ≤ 27 kg (60 lb); 1.0 g once daily for patients > 27 kg (60 lb) | Oral | Class I, LOE B |
| or | |||
| Erythromycin among patients with penicillin allergy | 250 mg twice daily | Oral | Class I, LOE C |
| Category | Duration | Rating |
|---|---|---|
| Rheumatic fever with carditis and residual heart disease (persistent valvular disease) | ≥ 10 years since last episode and at least until age 40 years; sometimes lifelong prophylaxis in high risk patients | Class I, LOE C |
| Rheumatic fever with carditis but no residual heart disease (no valvular disease) | 10 years or well into adulthood, whichever is longer | Class I, LOE C |
| Rheumatic fever without carditis | 5 years or until age 21 years, whichever is longer | Class I, LOE C |
Recurrence of rheumatic fever is higher among patients receiving oral prophylaxis than those receiving intramuscular benzathine penicillin G. This may be attributed to patient compliance i.e. patients prefer injection once in 4weeks over taking medicines daily. This observation was made in a study involving 405 children and adolescents with rheumatic fever assigned to receive 4 weeks of intramuscular benzathine penicillin G, oral penicillin G or oral sulfadiazine. Recurrence of rheumatic fever was observed in 0%, 4.8%, and 2.7% of the patients, respectively[3]. Therefore parenteral prophylaxis is recommended over oral prophylaxis
Sources
2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.[1]
References
- ↑ 1.0 1.1 1.2 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ 2.0 2.1 Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). "Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics". Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.
- ↑ FEINSTEIN AR, WOOD HF, EPSTEIN JA, TARANTA A, SIMPSON R, TURSKY E (1959). "A controlled study of three methods of prophylaxis against streptococcal infection in a population of rheumatic children. II. Results of the first three years of the study, including methods for evaluating the maintenance of oral prophylaxis". N Engl J Med. 260 (14): 697–702. doi:10.1056/NEJM195904022601405. PMID 13644570.