LUH OLIVA SARASWATI SUASTIKA

Department of Cardiology and Vascular Medicine

Faculty of Medicine, Udayana University, Bali
▪ An autoimmune, multi-organ
inflammatory disease that occurs
as a result of group A β-hemolytic
streptococcal (GAS) upper
respiratory infection in genetically
susceptible individuals.
▪ Occurs at all ages, peak: 5-15 years
▪ Chronic complication → rheumatic
heart disease
Prevalence in Indonesia (2013): 1.18 million
 LOW-RISK POPULATIONS
Those with RF incidence <2 per 100,000 school-age children
per year or all-age RHD prevalence of <1 per 1,000 population
Include: All of the United States, Canada, Western Europe

HIGH-RISK POPULATIONS
Those with RF incidence >2 per 100,000 school-age children
per year or all-age RHD prevalence of >1 per 1,000 population
Include: Maoris in New Zealand, Aborigines in Australia,
Pacific Islanders, and most developing countries
 ARF Incidence at Northern
Australia, 2011-2015
Source: AIHW analysis of Northern Territory Rheumatic Heart Disease
Program Register

Hospitalization with
diagnosis of ARF or RHD
by age & indigenous
status, 2013-2015
Source: AIHW analysis of National Hospital Morbidity
Database
2015 Revised Jones Criteria for diagnosis of Rheumatic Fever
2015 Revised Jones Criteria for Diagnosis of Rheumatic Fever
2015 Revised Jones Criteria for Diagnosis of Rheumatic Fever
❖ Subclinical carditis indicates echocardiographic valvulitis
(without murmur)
❖Erythema marginatum and subcutaneous nodules are rarely
“standalone” major criteria
❖Joint manifestations can only be considered in either major
or minor criterion but not both in the same patient
2015 Revised Jones Criteria for Diagnosis of Rheumatic Fever
 2015 Revised Jones Criteria for Diagnosis of Rheumatic Fever

The diagnosis of ARF should not be made in those patients

with elevated ASO titers who do not fulfill the Jones criteria
Throat culture of growing GABHS or elevated ASO titers
+
2 Major criteria OR
1 Major criteria AND 2 Minor criteria
 RECOMMENDED ANTIBIOTIC REGIMENS FOR
PRIMARY PREVENTION
(all ARF patients should receive)
ANTIBIOTIC DOSE ROUTE FREQUENCY
Benzathine Penicillin >27 kg: 1,200,000 U Deep im injection Once daily for 10 days
G <27 kg: 600,000 U
Penicillin V >27 kg: 500 mg Oral Twice daily for 10 days
<27 kg: 250 mg
Amoxicillin 50 mg/kg (max 1 g) Oral Once daily for 10 days
Penicillin alergy
Erythromycin 40 mg/kg/day Oral Divided into 3 doses,
for 10 days
Azithromycin 12 mg/kg (max 500 Oral Once daily for 5 days
mg)
Clindamycin 20 mg/kg/day (max Oral Divided into 3 doses,
1.8 g/day) for 10 days
 RECOMMENDED ANTIBIOTIC REGIMENS FOR
SECONDARY PROPHYLAXIS
ANTIBIOTIC DOSE ROUTE FREQUENCY
Benzathine Penicillin G >27 kg: 1,200,000 U Deep im injection Every 4 weekly
<27 kg: 600,000 U
Second line: if im route is not possible or refused, adherence should be carefully monitored
Phenoxymethylpenicillin 250 mg Oral Twice daily
(Penicillin V)
Penicillin alergy
Erythromycin 250 mg Oral Twice daily
 DURATION OF SECONDARY PROPHYLAXIS
CATEGORY DURATION
RF without carditis 5 years after most recent episode of ARF or until age
21 years (whichever is longer)

RF with carditis but no 10 years after most recent episode of ARF or until
residual VHD* age 21 years (whichever is longer).

RF with carditis and 10 years after most recent episode of ARF or until
persistent VHD* age 40 years (whichever is longer), or lifetime.

*VHD: valvular heart disease