Rheumatic fever medical therapy
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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]; Anthony Gallo, B.S. [4]
Overview
The mainstay of therapy for rheumatic fever includes antimicrobial therapy combined with anti-inflammatory medications. The drug of choice is penicillin, but ampicillin and amoxicillin are equally as effective. Supportive therapy for rheumatic fever includes continuous use of low dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence.
Medical Therapy
Antibiotic treatment in patients with rheumatic fever is aimed at eradication of Group A beta-hemolytic streptococci from the body. Patients with positive cultures for Streptococcus pyogenes and even those suspected to have strep infection should be treated with penicillin as long as allergy is not present. This treatment will not alter the course of the acute disease. Oral penicillin V is the drug of choice, but ampicillin and amoxicillin are equally effective. Intramuscular penicillin G benzathine is an alternative when oral penicillin is not feasible. Patients allergic to penicillin should be treated with cephalosporin or erythromycin.[1]
| Group | Measure: |
|---|---|
| Hospitalized patients | Droplet precautions and other standard precautions until 24 hours after initiation of antibiotics |
| People in contact with hospitalized patients | Evaluation for infection and treatment if infected |
| Infected children | Absence from school or childcare until 24 hours after initiation of antibiotics |
Arthritis/Arthralgia
The preferred drug for pain and inflammation in joints in rheumatic fever patients is paracetamol or salicylates.[2][3] Mild arthralgia and fever may respond to paracetamol alone. If arthalgia is severe, high dose of aspirin can be used. In this case, the patient should be monitored for symptoms of salicylate toxicity, such as tinnitus, headache, and hyperpnea.
Duration of treatment is usually 1-2 weeks and may be extended if the symptoms persists. When discontinuing therapy, aspirin should be discontinued gradually over weeks to avoid rebound reaction. Aggressive use of inflamed joints should be avoided to prevent permanent damage of joints.
Sydenham's chorea
The preferred drug for the treatment of Sydenham's chorea in rheumatic fever patients is sedation with diazepam or phenobarbital. In severe cases, patient should be placed at high risk of injury and treated with carbamazepine or valproic acid.[4][5] Sydenham's chorea is usually self limiting, resolving within few weeks.[6] Long term antibiotic prophylaxis is indicated in patients with Sydenham's chorea even in the absence of other manifestations of rheumatic fever. Chorea aggravates with emotional stress and attenuates with sleep. Anti-inflammatories such as glucocorticoids and aspirin have no effect on Sydenham's chorea.[7]
Heart failure
Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure which includes diuretics, ACE inhibitors and digoxin. Unlike normal heart failure, rheumatic heart failure responds well to corticosteroids.[8] Prednisone or prednisolone are the corticosteroids of choice with maximum dose being 80mg/day. The treatment with corticosteroids is usually for a period of 2-4 weeks after which the dose is tapered by 25% each week while maintaining high levels of salicylates to minimize adverse effects.
Valve defects
Mitral regurgitation or stenosis may develop in patients with rheumatic fever. Monitoring varies depending on extent of the disease.[1]
| Extent of mitral regurgitation | Monitoring |
|---|---|
| Mild | May remain asymptomatic, but should be followed regularly yearly |
| Moderate | Assess with echocardiogram yearly, or when symptoms develop |
| Severe | Absence from school or childcare until 24 hours after initiation of antibiotics |
There is no specific medical therapy for treatment of asymptomatic valvular disease secondary to rheumatic fever. In rheumatic fever induced aortic stenosis, antibiotic prophylaxis against recurrent rheumatic fever is indicated with cautious use of antihypertensives in treatment of coexisting systemic hypertension.[9]
Bacterial Endocarditis
Prophylaxis against infective endocarditis is not recommended in patients with rheumatic heart disease unless the patient has artificial heart valves, a history of previous episodes of endocarditis, or congenital heart disease.[9] In patients requiring endocarditis prophylaxis, it is recommended that an antibiotic from another class be administered.[10] The chronic antibiotic dose is usually lower than what is required for prevention of endocarditis. Furthermore, these individuals often are colonized with viridans group streptococci in their oral cavity that are relatively resistant to either penicillin or amoxicillin. In high risk patients, either clindamycin, azithromycin, or clarithromycin are recommended for prophylaxis prior to a dental procedure. As there is the potential for cross-resistance among Streptococcus viridans groups, cephalosporins are not recommended. Finally, if possible, it is recommended that elective procedures be delayed for 10 days to allow for recolonization with the usual flora.[11][12]
Contraindicated medications
Rheumatic fever is considered an absolute contraindication to the use of the following medications:
National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand Treatment Guidelines[13]
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All cases Single dose intramuscular penicillin G benzathine or oral penicillin V for 10 days (intravenous penicillin not needed; oral erythromycin may be used if patient allergic to penicillin)
Long-term preventive measures
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References
- ↑ 1.0 1.1 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.
- ↑ BYWATERS EG, THOMAS GT (1961). "Bed rest, salicylates, and steroid in rheumatic fever". Br Med J. 1 (5240): 1628–34. PMC 1954279. PMID 13689614.
- ↑ DORFMAN A, GROSS JI, LORINCZ AE (1961). "The treatment of acute rheumatic fever". Pediatrics. 27: 692–706. PMID 13723875.
- ↑ Peña J, Mora E, Cardozo J, Molina O, Montiel C (2002). "Comparison of the efficacy of carbamazepine, haloperidol and valproic acid in the treatment of children with Sydenham's chorea: clinical follow-up of 18 patients". Arq Neuropsiquiatr. 60 (2-B): 374–7. PMID 12131934.
- ↑ Genel F, Arslanoglu S, Uran N, Saylan B (2002). "Sydenham's chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens". Brain Dev. 24 (2): 73–6. PMID 11891095.
- ↑ LESSOF MH, BYWATERS EG (1956). "The duration of chorea". Br Med J. 1 (4982): 1520–3. PMC 1980122. PMID 13316200.
- ↑ Markowitz, M. & Gordis, L., Rheumatic Fever, 2nd ed. 1972. W.B. Saunders: Philadelphia
- ↑ Rheumatic Heart Disease. Textbook of Cardiology.org (2013) http://www.textbookofcardiology.org/wiki/Rheumatic_Heart_Disease Accessed on October 19, 2015.
- ↑ 9.0 9.1 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". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
- ↑ 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.
- ↑ Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F., Levison Matthew E., Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato, Taubert Kathryn A. (2005). "Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): 3167–84. PMID 15956145.
- ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT (2007). "American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. PMID 17446442.
- ↑ Carapetis JR, Brown A, Wilson NJ, Edwards KN, Rheumatic Fever Guidelines Writing Group (2007). "An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline". Med J Aust. 186 (11): 581–6. PMID 17547548.