You are on page 1of 3

Prevention of rheumatic fever in patients with group A beta hemolytic streptococci (GABHS) pharyngitis

For patients with GABHS pharyngitis, a meta-analysis supported a protective effect against rheumatic fever (RF) when penicillin is used following the diagnosis.4 • Oral (PO) penicillin V remains the drug of choice for treatment of GABHS pharyngitis, but ampicillin and amoxicillin are equally effective. • When PO penicillin is not feasible or dependable, a single dose of intramuscular benzathine penicillin G, or benzathine/procaine penicillin combination is therapeutic. • For patients who are allergic to penicillin, administer erythromycin or a first-generation cephalosporin. Other options include clarithromycin for 10 days, azithromycin for 5 days, or a narrow-spectrum (first-generation) cephalosporin for 10 days. As many as 15% of penicillin-allergic patients are also allergic to cephalosporins. • Do not use tetracyclines and sulfonamides to treat GABHS pharyngitis. • For recurrent group A streptococci (GAS) pharyngitis, a second 10-day course of the same antibiotic may be repeated. Alternate drugs include narrow-spectrum cephalosporins, amoxicillin-clavulanate, dicloxacillin, erythromycin, or other macrolides. • Control measures for patients with GABHS pharyngitis are as follows: ◦ Hospitalized patients: Place hospitalized patients with GABHS pharyngitis of pneumonia on droplet precautions, as well as standard precautions, until 24 hours after initiation of appropriate antibiotics. ◦ Exposed persons: People in contact with patients having documented cases of streptococcal infection first should undergo appropriate laboratory testing if they have clinical evidence of GABHS infection and should undergo antibiotic therapy if infected. ◦ School and childcare centers: Children with GABHS infection should not attend school or childcare centers for the first 24 hours after initiating antimicrobial therapy. • GABHS carriage is difficult to eradicate with conventional penicillin therapy. Thus, PO clindamycin (20 mg/kg/d PO in 3 divided doses for 10 d) is recommended. • In general, antimicrobial therapy is not indicated for pharyngeal carriers of GABHS. Exceptions include the following: ◦ Outbreaks of rheumatic fever or poststreptococcal glomerulonephritis ◦ Family history of rheumatic fever ◦ During outbreaks of GAS pharyngitis in a closed community ◦ When tonsillectomy is considered for chronic GABHS carriage ◦ When multiple episodes of documented GABHS pharyngitis occur within a family despite appropriate therapy ◦ Following GAS toxic shock syndrome or necrotizing fasciitis in a household contact

Treatment for patients with rheumatic fever

Therapy is directed towards eliminating the GABHS pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment of congestive heart failure (CHF).

• When heart failure persists or worsens during the acute phase after aggressive medical therapy. ◦ Initiate digoxin only after checking electrolytes and correcting abnormalities in serum potassium. add PO prednisone to salicylate therapy. with 50% of the dose administered initially. ◦ When discontinuing therapy.25-1. and the maintenance dose is 0. surgery is indicated to decrease valve insufficiency. followed by 25% of the dose 8 hours and 16 hours after the initial dose. ◦ If rapid improvement is not observed after 24-36 hours of therapy. the total loading dose is 1. using ACE inhibitor captopril) may be effective in improving cardiac output. • Afterload reduction (ie.5 mg PO. Treatment for patients following rheumatic heart disease (RHD) Preventive and prophylactic therapy is indicated after rheumatic fever and RHD to prevent further damage to valves. third-degree heart block. question the diagnosis of rheumatic fever. ◦ Anti-inflammatory doses of aspirin may be associated with abnormal liver function tests and GI toxicity. but stable levels may be difficult to achieve during the inflammatory phase because of variable GI absorption of the drug. afterload reduction. • If moderate to severe carditis is present as indicated by cardiomegaly. ◦ Continue prednisone for 2-6 weeks depending on the severity of the carditis. Therapeutic digoxin levels are present at trough levels of 1. ◦ Discontinuing prednisone therapy after 2-4 weeks. supplemental oxygen. Aspirin in anti-inflammatory doses effectively reduces all manifestations of the disease except chorea. withdraw aspirin gradually over weeks while monitoring the APRs for evidence of rebound. particularly in the presence of mitral and aortic insufficiency.25-0. initial test dose (some patients have an abnormally large response to these agents). • Include digoxin and diuretics.• Treat residual GABHS pharyngitis as outlined above. and the response typically is dramatic. . and administer only after correcting hypovolemia. ◦ The total loading dose is 20-30 mcg/kg PO every day. if still present. • Treatment of the acute inflammatory manifestations of acute rheumatic fever consists of salicylates and steroids. while maintaining salicylates for an additional 2-4 weeks. The diuretics most commonly used in conjunction with digoxin for children with CHF include furosemide and spironolactone.5-2 ng/mL. ◦ Attempt to obtain aspirin blood levels from 20-25 mg/dL.5 mg PO every day. Use a small. and adjusting the aspirin dosage may be necessary. and taper prednisone during the last week of therapy. For older children and adults. Maintenance doses typically are 8-10 mcg/kg/d PO in 2 divided doses. can minimize adverse effects. bed rest. Maintain aspirin at anti-inflammatory doses until the signs and symptoms of acute rheumatic fever are resolved or residing (6-8 wk) and the acute phase reactants (APRs) have returned to normal. Chorea most frequently is self-limited but may be alleviated or partially controlled with phenobarbital or diazepam. and sodium and fluid restriction as additional treatment for patients with acute rheumatic fever and CHF. Start these agents judiciously. or CHF.

Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic. whichever is longer. .2 million units of benzathine penicillin G intramuscularly every 4 weeks is the recommended regimen for secondary prophylaxis for most US patients.• Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis (prevention of recurrent rheumatic fever and RHD). Finally.6-1. continue prophylaxis indefinitely. the American Heart Association currently recommends that patients with rheumatic fever without carditis receive prophylactic antibiotics for 5 years or until aged 21 years. daycare workers) for recurrent GABHS infection. in patients with residual carditis. ◦ Although PO penicillin prophylaxis is also effective.5Patients with rheumatic fever with carditis but no valve disease should receive prophylactic antibiotics for 10 years or well into adulthood. • An injection of 0. because recurrent GABHS infection and rheumatic fever can occur at any age. and in high-risk patients. whichever is longer. data from the World Health Organization indicate that the recurrence risk of GABHS pharyngitis is lower when penicillin is administered parentally. ◦ The duration of antibiotic prophylaxis is controversial. teachers. however. Ideally. health care workers. Continue antibiotic prophylaxis indefinitely for patients at high risk (eg. patients with rheumatic fever with carditis and valve disease should receive antibiotics at least 10 years or until aged 40 years.