Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis

Abstract

Abstract-Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A ␤-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them. (Circulation. 2009;119:1541-1551.)

2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease

“…Lifelong prophylaxis should be considered in high-risk patients according to the severity of VHD and exposure to group A Streptococcus. [29][30][31] 3.6 Concept of the Heart Team and heart valve centres…”

No evidence yet to change American Heart Association recommendations for poststreptococcal reactive arthritis: Comment on the article by van Bemmel et al

“…None of the patients developed clinical or echocardiographic evidence of valvular disease or cardiac involvement at the time of disease onset or during followup. As recommended (2), all children received intramuscular benza- thine penicillin prophylaxis, which was discontinued after 1 year, since evidence of carditis was not detected. We agree with van Bemmel et al that abnormal cardiac findings following poststreptococcal ReA are extremely rare, although it has been previously reported that a small proportion of patients with poststreptococcal ReA may subsequently develop carditis (4,7,8), making poststreptococcal ReA part of the spectrum of ARF.…”

“…Our goal was to determine the increased risk of carditis (previously unknown) in adult patients with poststreptococcal ReA. Studies on ARF have shown that the risk of carditis in adults is lower than in children (33% versus 50%) (1)(2)(3). In children with poststreptococcal ReA, the risk of carditis is ϳ8% (1-3), and in adults, as mentioned above, the risk had yet to be determined.…”

The experience of intramuscular benzathine penicillin for prophylaxis of recurrent cellulitis: A cohort study

“…Although these studies showed evidence of effectiveness of prophylaxis strategies, there were still limitations to make a conclusion on the optimal method for preventing recurrent cellulitis. 9,10 Because benzathine penicillin has been consistently active to Group A streptococcus in Taiwan, 11 it has been suggested for secondary prevention of rheumatic fever, 12 and has shown some evidence of effectiveness on prevention of recurrent cellulitis, 3 intramuscular benzathine penicillin at a 4-week interval has been adopted as the prophylactic strategy for recurrent cellulitis in our hospital. However, the evidence to support our common practice was not robust.…”