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==Overview== | ==Overview== | ||
The mainstay of therapy for rheumatic fever | The mainstay of [[therapy]] for rheumatic fever includes [[antimicrobial]] [[therapy]] combined with [[anti-inflammatory medication]]s. 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 [[antibiotic]]s (such as [[penicillin]], [[sulfadiazine]], or [[erythromycin]]) to prevent recurrence. | ||
==Medical Therapy== | ==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 benzathine | 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]].<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
! | ! Group | ||
! | ! Measure: | ||
|- | |- | ||
| Hospitalized patients | | Hospitalized patients | ||
| Droplet precautions and other standard precautions until 24 hours after initiation of antibiotics | | Droplet precautions and other standard precautions until 24 hours after initiation of antibiotics | ||
|- | |- | ||
| People in contact with | | People in contact with hospitalized patients | ||
| Evaluation for infection and treatment if infected | | Evaluation for infection and treatment if infected | ||
|- | |- | ||
| Line 24: | Line 24: | ||
===Arthritis/Arthralgia=== | ===Arthritis/Arthralgia=== | ||
The preferred drug for pain and inflammation in joints in rheumatic fever patients is [[paracetamol]] or [[salicylates]].<ref name="pmid13689614">{{cite journal| author=BYWATERS EG, THOMAS GT| title=Bed rest, salicylates, and steroid in rheumatic fever. | journal=Br Med J | year= 1961 | volume= 1 | issue= 5240 | pages= 1628-34 | pmid=13689614 | doi= | pmc=PMC1954279 | url= }} </ref><ref name="pmid13723875">{{cite journal| author=DORFMAN A, GROSS JI, LORINCZ AE| title=The treatment of acute rheumatic fever. | journal=Pediatrics | year= 1961 | volume= 27 | issue= | pages= 692-706 | pmid=13723875 | doi= | pmc= | url= }} </ref> 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]], | The preferred drug for [[pain]] and [[inflammation]] in [[joints]] in rheumatic fever [[patients]] is [[paracetamol]] or [[salicylates]].<ref name="pmid13689614">{{cite journal| author=BYWATERS EG, THOMAS GT| title=Bed rest, salicylates, and steroid in rheumatic fever. | journal=Br Med J | year= 1961 | volume= 1 | issue= 5240 | pages= 1628-34 | pmid=13689614 | doi= | pmc=PMC1954279 | url= }} </ref><ref name="pmid13723875">{{cite journal| author=DORFMAN A, GROSS JI, LORINCZ AE| title=The treatment of acute rheumatic fever. | journal=Pediatrics | year= 1961 | volume= 27 | issue= | pages= 692-706 | pmid=13723875 | doi= | pmc= | url= }} </ref> 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. | 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=== | ===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]].<ref name="pmid12131934">{{cite journal| author=Peña J, Mora E, Cardozo J, Molina O, Montiel C| title=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. | journal=Arq Neuropsiquiatr | year= 2002 | volume= 60 | issue= 2-B | pages= 374-7 | pmid=12131934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12131934 }} </ref><ref name="pmid11891095">{{cite journal| author=Genel F, Arslanoglu S, Uran N, Saylan B| title=Sydenham's chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens. | journal=Brain Dev | year= 2002 | volume= 24 | issue= 2 | pages= 73-6 | pmid=11891095 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11891095 }} </ref> Sydenham's chorea is usually self limiting, resolving within few weeks.<ref name="pmid13316200">{{cite journal| author=LESSOF MH, BYWATERS EG| title=The duration of chorea. | journal=Br Med J | year= 1956 | volume= 1 | issue= 4982 | pages= 1520-3 | pmid=13316200 | doi= | pmc=PMC1980122 | url= }} </ref> 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 [[glucocorticoid]]s and [[aspirin]] have no effect on Sydenham's chorea.<ref>Markowitz, M. & Gordis, L., Rheumatic Fever, 2nd ed. 1972. W.B. Saunders: Philadelphia</ref> | 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]].<ref name="pmid12131934">{{cite journal| author=Peña J, Mora E, Cardozo J, Molina O, Montiel C| title=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. | journal=Arq Neuropsiquiatr | year= 2002 | volume= 60 | issue= 2-B | pages= 374-7 | pmid=12131934 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12131934 }} </ref><ref name="pmid11891095">{{cite journal| author=Genel F, Arslanoglu S, Uran N, Saylan B| title=Sydenham's chorea: clinical findings and comparison of the efficacies of sodium valproate and carbamazepine regimens. | journal=Brain Dev | year= 2002 | volume= 24 | issue= 2 | pages= 73-6 | pmid=11891095 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11891095 }} </ref> [[Sydenham's chorea]] is usually self limiting, resolving within few weeks.<ref name="pmid13316200">{{cite journal| author=LESSOF MH, BYWATERS EG| title=The duration of chorea. | journal=Br Med J | year= 1956 | volume= 1 | issue= 4982 | pages= 1520-3 | pmid=13316200 | doi= | pmc=PMC1980122 | url= }} </ref> 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 inflammatory medications|Anti-inflammatories]] such as [[glucocorticoid]]s and [[aspirin]] have no effect on [[Sydenham's chorea|Sydenham's chorea.]]<ref>Markowitz, M. & Gordis, L., Rheumatic Fever, 2nd ed. 1972. W.B. Saunders: Philadelphia</ref> | ||
===Heart failure=== | ===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]].<ref name=CardTB> Rheumatic Heart Disease. Textbook of Cardiology.org (2013) http://www.textbookofcardiology.org/wiki/Rheumatic_Heart_Disease Accessed on October 19, 2015.</ref> [[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 [[salicylate]]s to minimize adverse effects. | 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]].<ref name="CardTB"> Rheumatic Heart Disease. Textbook of Cardiology.org (2013) http://www.textbookofcardiology.org/wiki/Rheumatic_Heart_Disease Accessed on October 19, 2015.</ref> [[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 [[salicylate]]s to minimize [[adverse effects]]. | ||
===Valve defects=== | ===Valve defects=== | ||
[[Mitral regurgitation]] or [[stenosis]] may develop in patients with rheumatic fever. | [[Mitral regurgitation]] or [[stenosis]] may develop in [[patients]] with rheumatic fever. Monitoring varies depending on extent of the [[disease]].<ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172 }} </ref> | ||
{| class="wikitable" | |||
! 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 [[antihypertensive]]s in treatment of coexisting [[systemic]] [[hypertension]].<ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref> | |||
====Bacterial Endocarditis==== | ====Bacterial Endocarditis==== | ||
Prophylaxis against [[infective endocarditis]] is not recommended in patients with rheumatic heart disease unless the patient has | Prophylaxis against [[infective endocarditis]] is not recommended in [[patients]] with rheumatic heart disease unless the [[patient]] has [[artificial heart valve]]s, a history of previous episodes of [[endocarditis]], or [[congenital heart disease]].<ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref> In [[patients]] requiring [[Endocarditis antibiotic prophylaxis|endocarditis prophylaxis]], it is recommended that an [[antibiotic]] from another class be administered.<ref name="pmid19246689">{{cite journal| author=Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST et al.| title=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. | journal=Circulation | year= 2009 | volume= 119 | issue= 11 | pages= 1541-51 | pmid=19246689 | doi=10.1161/CIRCULATIONAHA.109.191959 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19246689 }} </ref> The chronic [[antibiotic]] dose is usually lower than what is required for [[prevention]] of [[endocarditis]]. Furthermore, these individuals often are colonized with [[Streptococcus viridans|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, [[cephalosporin]]s 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]].<ref name="Baddour">{{cite journal | author = 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.| title = 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. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145}}</ref><ref name="Wilson">{{cite journal | author = 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| title = 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| journal = Circulation | volume = 116 | issue = 15|pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref> | ||
===Contraindicated medications=== | ===Contraindicated medications=== | ||
| Line 56: | Line 66: | ||
'''All cases''' | '''All cases''' | ||
Single dose intramuscular | 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) | ||
'''[[Arthritis]] and [[fever]]''' | '''[[Arthritis]] and [[fever]]''' | ||
| Line 62: | Line 72: | ||
*[[Paracetamol]] (first-line) or [[codeine]] until diagnosis confirmed | *[[Paracetamol]] (first-line) or [[codeine]] until diagnosis confirmed | ||
*[[Aspirin]] (first-line) or [[naproxen]] once diagnosis confirmed, if [[arthritis]] or severe [[arthralgia]] present | *[[Aspirin]] (first-line) or [[naproxen]] once diagnosis confirmed, if [[arthritis]] or severe [[arthralgia]] present | ||
*Mild arthralgia and fever may respond to paracetamol alone | *Mild [[arthralgia]] and [[fever]] may respond to paracetamol alone | ||
*[[Influenza vaccine]] for children receiving aspirin during the influenza season (autumn/winter) | *[[Influenza vaccine]] for children receiving aspirin during the influenza season (autumn/winter) | ||
| Line 72: | Line 82: | ||
'''[[Carditis]]/[[heart failure]]''' | '''[[Carditis]]/[[heart failure]]''' | ||
*Bed-rest | *Bed-rest | ||
*Urgent echocardiogram | *Urgent [[echocardiogram]] | ||
*Anti-heart failure medication | *Anti-heart failure medication | ||
**[[Diuretics]]/fluid restriction for mild to moderate heart failure | **[[Diuretics]]/fluid restriction for mild to moderate heart failure | ||
| Line 78: | Line 88: | ||
**[[Glucocorticoid]]s optional for severe [[carditis]] (consider treating for possible opportunistic infections) | **[[Glucocorticoid]]s optional for severe [[carditis]] (consider treating for possible opportunistic infections) | ||
**[[Digoxin]] if atrial fibrillation present | **[[Digoxin]] if atrial fibrillation present | ||
*Valve surgery for life-threatening acute carditis (rare) | *Valve surgery for life-threatening acute [[carditis]] (rare) | ||
'''Long-term preventive measures''' | '''Long-term preventive measures''' | ||
*Give first dose of [[Rheumatic fever secondary prevention|secondary prophylaxis]] | *Give first dose of [[Rheumatic fever secondary prevention|secondary prophylaxis]] | ||
*Notify case for recording in | *Notify case for recording in acute rheumatic fever/rheumatic heart disease register, if available | ||
*Contact local health staff to ensure follow-up | *Contact local health staff to ensure follow-up | ||
*Provide culturally appropriate education to patient and family | *Provide culturally appropriate education to patient and family | ||
*Arrange dental review and ongoing dental care to reduce risk of [[endocarditis]]}} | *Arrange dental review and ongoing dental care to reduce risk of [[endocarditis]]}} | ||
<br /> | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Rheumatology]] | [[Category:Rheumatology]] | ||
Latest revision as of 00:00, 30 July 2020
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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]
| “ |
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
|
” |
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.
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- ↑ 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.