Rheumatic fever secondary prevention


 * Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: ;

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.

Alternatives to benzathine penicillin G are available, although they are less effective and require careful monitoring.
 * In patients who refuse intramuscular benzathine penicillin G, oral penicillin can be offered, although it is less effective than benzathine penicillin G in preventing GAS infections and subsequent recurrences of ARF. For patients taking oral penicillin, the consequences of missed doses must be emphasised, and adherence monitored.
 * In patients who may be allergic to penicillin, an allergist should be consulted. The rates of allergic and anaphylactic reactions to monthly benzathine penicillin G are low, and fatal reactions are exceptionally rare. There is no increased risk with prolonged benzathine penicillin G use.
 * In patients with a confirmed, immediate, and severe allergic reaction to penicillin, a nonbeta-lactam antimicrobial (e.g., erythromycin) should be used instead of benzathine penicillin G.
 * In pregnant patients, penicillin prophylaxis should continue for the duration of pregnancy to prevent recurrent ARF. There is no evidence of teratogenicity. Erythromycin is also considered safe in pregnancy, although controlled trials have not been conducted.
 * In anticoagulated patients, benzathine penicillin G injections should be continued unless there is evidence of uncontrolled bleeding, or the international normalised ratio is outside the defined therapeutic window. Intramuscular bleeding is rare when benzathine penicillin G injections are used in conjunction with anticoagulation therapy.

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. Therefore parenteral prophylaxis is recommended over oral prophylaxis

Secondary prophylaxis for 1 year among patients with post streptococcal reactive arthritis (PSRA) is recommended by some as few PSRA patients have been observed to develop valvular heart disease.