eMedicine Specialties > Infectious Diseases > Cardiovascular and Intravascular Infections
Rheumatic Fever: Treatment & Medication
Updated: Apr 13, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Management and prevention of acute rheumatic fever (ARF) can be divided into the following 4 approaches:
- Treatment of the group A streptococcal infection that led to the disease: Although never proven to improve the one-year outcome, this is a standard practice.6,1 It may at least serve to reduce the spread of rheumatogenic strains.
- General treatment of the acute episode
- Anti-inflammatory agents are used to control the arthritis, fever, and other acute symptoms. Salicylates are the preferred agents, although other nonsteroidal agents are probably equally efficacious. Steroids are also effective but should probably be reserved for patients in whom salicylates fail. None of these anti-inflammatory agents has been shown to reduce the risk of subsequent rheumatic heart disease.
- Bed rest is a traditional part of ARF therapy and is especially important in those with carditis. Patients are typically advised to rest through the acute illness and to then gradually increase activity; some clinicians monitor the patient’s ESR and restart activity only as it normalizes.6,1
- Intravenous immunoglobulin has not been shown to reduce the risk of rheumatic heart disease or to substantially improve the clinical course.24
- Chorea is usually managed conservatively in a quiet nonstimulatory environment; valproic acid is the preferred agent if sedation is needed. Intravenous immunoglobulin, steroids, and plasmapheresis have all been used successfully in refractory chorea, although conclusive evidence of their efficacy is limited.6,14
- Cardiac management: Bed rest is essential in patients with cardiac involvement. Carditis resulting in heart failure is treated with conventional measures; some use corticosteroids for severe carditis, although data to support this are scant.6 Diuretics are the mainstay of therapy. Monitor for development of arrhythmias in patients with active myocarditis.
- Penicillin prophylaxis (see Medication)
Surgical Care
Surgical care is not typically indicated in ARF. Surgical intervention is required only to treat long-term valvular cardiac sequelae of ARF that cause stenosis.
Consultations
- Consultation with a cardiologist may be required to manage heart blocks and CHF.
- Consultation with a neurologist or psychiatrist may be required to confirm the diagnosis of chorea and to assist in its management.
- Consultations with an infectious disease specialist and rheumatologist may be helpful in diagnosis.
Diet
No specific dietary recommendation exists. CHF may require salt restriction.
Activity
Bed rest is a time-honored part of ARF therapy and is especially important in those with carditis. Patients are typically advised to rest through the acute illness and to then gradually increase activity; some clinicians monitor the ESR and restart activity only as it normalizes.6,1
Medication
Antibiotics
Antibiotic treatment in patients who present with acute rheumatic fever (ARF) is necessary irrespective of the throat culture result. Such therapy probably does not alter the risk of developing rheumatic heart disease but at least minimizes the possible transmission of a rheumatogenic streptococcal strain.1
Primary prophylaxis (treatment of streptococcal pharyngitis) dramatically reduces the risk of ARF and should be provided whenever a group A streptococcal pharyngitis is confirmed.
Secondary prevention is required to prevent additional streptococcal infections and is the critical step in management of ARF. Patients with a history of rheumatic fever are at a high risk of recurrent ARF, which may further the cardiac damage. The exact duration of chronic antimicrobial prophylaxis remains controversial, but the WHO guidelines are commonly used.1 There had been concern that sustained benzathine penicillin as secondary prophylaxis would lead to the development of resistant strains of Streptococcus viridans, but a recent study found no support for this hypothesis.25
Rheumatic fever with carditis and clinically significant residual heart disease requires antibiotic treatment for a minimum of 10 years after the latest episode; prophylaxis is required until the patient is aged at least 40-45 years and is often continued for life.
Rheumatic fever with carditis and no residual heart disease aside from mild mitral regurgitation requires antibiotic treatment for 10 years or until age 25 years (whichever is longer).
Rheumatic fever without carditis requires antibiotic treatment for 5 years or until the patient is aged 18-21 years (whichever is longer).
Children given penicillin G benzathine at a dose of 1.2 million U IM q4wk experienced a recurrence rate of 0.4 cases per 100 patient-years of observation. ARF recurrence rates have been found to be even lower if penicillin is administered q3wk instead of q4wk. This regimen may be appropriate in patients with severe rheumatic heart disease. Weigh the benefits of a 3-week regimen against patient compliance and cost. Long-term administration of oral penicillin may be used in lieu of the intramuscular route. Erythromycin or sulfadiazine may be used in patients who are allergic to penicillin.6,1
Penicillin G benzathine (Bicillin L-A)
Long-acting depot form of penicillin G. DOC for prophylaxis of streptococcal pharyngitis. Avoids compliance problems of oral regimens.
Adult
Primary prophylaxis (treatment of group A streptococcal pharyngitis): 1.2 million U IM once
Secondary prophylaxis: 1.2 million U IM q3-4wk
Pediatric
Primary prophylaxis (<27 kg): 600,000 U IM once
Secondary prophylaxis: 600,000 U IM q3-4wk
Probenecid decreases clearance, causing increased penicillin effect; tetracyclines are bacteriostatic, possibly decreasing the effectiveness of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution if abnormal renal function, adjust dose accordingly
Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K, Robicillin VK, V-Cillin K)
Phenoxymethyl derivative of penicillin G is acid-stable, enhancing oral bioavailability. Patient compliance is essential for effectiveness.
Adult
Primary prophylaxis (treatment of streptococcal pharyngitis): 500 mg PO bid/tid for 10 d
Secondary prophylaxis: 250 mg PO bid
Pediatric
Primary prophylaxis: 250 mg PO bid/tid for 10 d
Secondary prophylaxis:
<5 years: 125 mg PO bid
>5 years: 250 mg PO bid
Probenecid decreases clearance, causing increased penicillin effect; tetracyclines are bacteriostatic, possibly decreasing effectiveness of penicillins
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal impairment, adjust dose accordingly
Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab, Erythrocin, E-Mycin)
Macrolides inhibit protein synthesis, in contrast to penicillin cell wall effects. DOC for primary treatment of streptococcal pharyngitis in penicillin allergy. May use for secondary prophylaxis in patients allergic to penicillin.
Adult
Primary prophylaxis: 250 mg erythromycin stearate, base, or estolate salts (or 400 mg ethylsuccinate) q6h PO or 500 mg PO q12h for 10 d; not to exceed 1 g/d; alternatively, 333 mg (as the base) q8h
Secondary prophylaxis: 250 mg PO bid
Pediatric
Primary prophylaxis: 30-50 mg/kg/d (base or ethylsuccinate) PO divided q6-8h; not to exceed 1 g/d
Secondary prophylaxis (base or ethylsuccinate):
<5 years: 125 mg PO bid
>5 years: 250 mg PO bid
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; inhibits CYP1A2 CYP3A4 isoenzymes
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease, estolate formulation may cause cholestatic jaundice; GI adverse effects are common; discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Sulfadiazine (Microsulfon)
Exerts bacteriostatic action through competitive antagonism with para-aminobenzoic acid (PABA). Microorganisms that require exogenous folic acid and do not synthesize folic acid are not susceptible to the action of sulfonamides. Used in secondary prophylaxis of ARF.
Adult
1 g PO qd
Pediatric
<27 kg: 500 mg PO qd
>27 kg: 1 g/d PO
Increases effect of oral anticoagulants and oral hypoglycemic agents; PABA or PABA metabolites of drugs (eg, tetracaine, sunscreens, procaine) decrease sulfadiazine effect
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in impaired renal/hepatic function (adjust dose); G-6-PD deficiency
Anti-inflammatory agents
Salicylates and corticosteroids are the mainstay of the anti-inflammatory treatment of ARF. Avoid anti-inflammatory drugs until diagnosis is confirmed, as they may mask symptoms essential to the diagnosis. Analgesics without anti-inflammatory properties (ie, codeine) are used for mild disease. Corticosteroids and salicylates cannot prevent or modify the development of subsequent rheumatic heart disease but are used for symptomatic relief. Some experts believe steroids are of value in patients with severe or fulminant carditis, but data are sparse.6
Clinical or laboratory manifestations of rheumatic inflammation may recur upon cessation of anti-inflammatory therapy. Rebound occurs frequently with corticosteroids; hence, they require gradual tapering rather than abrupt cessation. Salicylates are usually continued for a month following corticosteroid discontinuance.
Aspirin (Anacin, Ascriptin, Bayer Aspirin, Bayer Buffered Aspirin)
Used in patients with moderate-to-severe arthritis and carditis without heart failure. Treatment is administered for at least 8 wk.
Adult
90-100 mg/kg/d PO divided q6-8h for 2 wk initially, then 60-70 mg/kg/d for 6 wk; not to exceed 3.6-5.4 g/d
Pediatric
60-90 mg/kg/d PO divided q6-8h for 8 wk; adjust according to serum levels
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs; serum levels of 20-30 mg/100 dL are required to control inflammatory response; high doses may cause gastric irritation or salicylate toxicity (ie, serum levels >20 mg/100 dL) and require dose reduction or alternative treatment with corticosteroids
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid with severe anemia, blood coagulation defects, or anticoagulants; relative contraindications include hepatic dysfunction, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, and asthma; due to association of aspirin with Reye syndrome, do not use in children (<16 y) who have influenza or varicella
Prednisone (Deltasone, Liquid-Pred, Meticorten, Orasone, Sterapred)
Used in severe carditis and CHF. High-dose prednisone is administered for 2-3 wk, then tapered over 3 wk. IV corticosteroids are reserved for fulminant cases.
Adult
40-60 mg PO qd for 2-3 wk initially, then discontinue by gradual taper over 3 wk
Pediatric
0.05-2 mg/kg PO qd for 2-3 wk initially, then discontinue by gradual taper over 3 wk
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (adjust dose); hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; significant hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; may cause hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections
More on Rheumatic Fever |
| Overview: Rheumatic Fever |
| Differential Diagnoses & Workup: Rheumatic Fever |
 Treatment & Medication: Rheumatic Fever |
| Follow-up: Rheumatic Fever |
| References |
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References
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Further Reading
Keywords
rheumatic fever, acute rheumatic fever, ARF, rheumatic heart disease, RHD, group A streptococcal pharyngitis, streptococcal pharyngitis, group A streptococci, group A Streptococcus, group A beta-hemolytic Streptococcus, group A beta-hemolytic streptococci, Duckett Jones criteria, Duckett-Jones criteria
