VOLUME 45 : NUMBER 4 : AUGUST 2022

ARTICLE

Therapeutics for rheumatic fever and

rheumatic heart disease
Anna P Ralph
Division lead, Global and
Tropical Health1
SUMMARY
Past director and Senior The goals of acute rheumatic fever therapy are to relieve symptoms, mitigate cardiac valve
clinical advisor2 damage and eradicate streptococcal infection. Preventing future recurrences requires long-term
Senior staff specialist3 secondary antibiotic prophylaxis and ongoing prevention of Streptococcus pyogenes (group A
Bart J Currie streptococcus) infections.
Professor in Medicine1
The recommended regimen for secondary prophylaxis comprises benzathine benzylpenicillin G
Past director2
intramuscular injections every four weeks. For patients with non-severe or immediate penicillin
Senior staff specialist3
hypersensitivity, use erythromycin orally twice daily.
1
Menzies School of Health
The goals of therapy for rheumatic heart disease are to prevent progression and optimise
Research, Charles Darwin
University, Darwin cardiac function. Secondary antibiotic prophylaxis can reduce the long-term severity of rheumatic
2
RHDAustralia, Menzies
heart disease.
School of Health Research, Patients with rheumatic heart disease, including those receiving benzathine benzylpenicillin G
Darwin
prophylaxis, should receive amoxicillin prophylaxis before undergoing high-risk dental or surgical
3
Department of Infectious
procedures. If they have recently been treated with a course of penicillin or amoxicillin, or have
Diseases, Royal Darwin
and Palmerston Hospitals,
immediate penicillin hypersensitivity, clindamycin is recommended.
Northern Territory Health

Introduction What is rheumatic fever and

Keywords who gets it?
rheumatic fever, rheumatic At least 8000 people in Australia currently have
heart disease acute rheumatic fever or rheumatic heart disease. In less than 10% of the population, infection with
The conditions are notifiable in the Northern Streptococcus pyogenes (group A streptococcus)
Territory, Western Australia, Queensland, South can trigger autoimmune conditions including
Aust Prescr 2022;45:104–12
Australia and New South Wales. The Rheumatic acute rheumatic fever or acute post-streptococcal
https://doi.org/10.18773/
Heart Disease Control Programs in these jurisdictions glomerulonephritis days to months after the initial
austprescr.2022.034
are important sources of support for healthcare infection.4 Acute rheumatic fever is not a homogenous
providers.1 Nationally, Rheumatic Heart Disease condition and shows high immunological5 and clinical2
Australia provides educational resources for providers, diversity. It can also be subtle and mimic other
patients and families. conditions. There is no dedicated diagnostic test, and
instead it is diagnosed using the Jones criteria.6 These
Important changes were made to the therapeutic
factors make the diagnosis highly challenging. In up to
recommendations in the 2020 Australian Guideline
75% of people with rheumatic heart disease, previous
for Prevention, Diagnosis and Management of Acute
acute rheumatic fever was unrecognised.7
Rheumatic Fever and Rheumatic Heart Disease.2,3 The
duration of secondary prophylaxis after a diagnosis The abnormal immune responses characterising
of acute rheumatic fever or rheumatic heart disease acute rheumatic fever chiefly occur in immature
is now shorter for some people without cardiac immune systems, with the peak incidence occurring
involvement. Non-steroidal anti-inflammatory at 5–14 years of age. The risk increases with repeated
drugs (NSAIDs) such as naproxen or ibuprofen are exposure to streptococci.8 Most cases occur when
now the recommended first-line drugs for arthritis the exposure risk is high, such as in crowded living
instead of aspirin. Lidocaine (lignocaine) is no conditions or when there is inadequate access to
longer contraindicated with intramuscular injections sanitation facilities and health care.9,10
of benzathine benzylpenicillin G. Endocarditis Acute rheumatic fever also affects adults. Approximately
prophylaxis is now recommended for all patients with 7% of notifications in Australia are in 35–44 year olds.11
rheumatic heart disease, not just for Aboriginal and In Australia, nearly 90% of acute rheumatic fever
Torres Strait Islander people. cases and 70% of rheumatic heart disease diagnoses

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are in Aboriginal and Torres Strait Islander people.11 considered in a child with a high risk of streptococcal
Migrants or second-generation Australians from exposure presenting with unexplained fever.
regions with a high streptococcal burden and low- Electrocardiography, measurements of inflammatory
income countries, especially Maori and Pacific Islander markers (C-reactive protein concentrations,
populations, also have an elevated risk (Box).2 erythrocyte sedimentation rate), streptococcal
serologic tests and echocardiography may all be
Diagnosis
indicated for investigation, as fever can be the only
The diagnosis of acute rheumatic fever requires sign that the child has acute rheumatic fever.
actively excluding alternative diagnoses, followed by
Sydenham chorea is a neuropsychiatric manifestation
applying the Jones criteria,6 which can be facilitated
of acute rheumatic fever characterised by chorea,
using the ARF RHD Guideline mobile phone app. The
decreased muscle tone and sometimes psychiatric
role of echocardiography in diagnosis and follow-up
and behavioural symptoms. It may occur weeks to
has become increasingly emphasised.
months after the onset of streptococcal infection
In Australia, approximately 50% of cases involve depending on the history of disease recurrence
a fever with joint pain.12 Joint pain associated with and time of diagnosis, and thus fever, elevated
rheumatic fever may be subtle (no heat, effusion or concentrations of inflammatory markers and elevated
erythema of the joints; only pain and limping) or florid streptococcal serology may be absent.
with classical migratory polyarthritis, predominantly
affecting large joints. Carditis with arthritis is the next Management of acute rheumatic fever
most common manifestation, followed in decreasing Symptom management is critical to reduce morbidity
order by chorea, carditis alone or other combinations and return children home and to school. The goals of
of these ‘major’ Jones criteria. Erythema marginatum acute rheumatic fever therapy are to:
and subcutaneous nodules are reported in less than • relieve symptoms
1% of local cases.12
• mitigate cardiac damage
Carditis alone may comprise only fever with evidence
• eradicate the inciting streptococcal infection
of valve disease, such as mitral valve thickening
and mild regurgitation on echocardiography. It • prevent future recurrences.
may manifest with or without a murmur and with Hospitalisation for rheumatic fever is recommended
or without a conduction abnormality seen on to confirm the diagnosis and facilitate prompt
electrocardiography, such as first-degree heart access to an echocardiogram. A variety of doctors
block. Acute rheumatic fever should therefore be (paediatricians, physicians, cardiologists, GPs) with

Box Groups at risk of acute rheumatic fever and rheumatic heart disease

At high risk
• People living in an acute rheumatic fever-endemic setting*
• Aboriginal and Torres Strait Islander people living in rural or remote areas
• Aboriginal and Torres Strait Islander people and Maori and Pacific Islander people living in metropolitan households
affected by crowding or low socioeconomic status
• Patients with a personal history of acute rheumatic fever or rheumatic heart disease and <40 years of age

May be at high risk

• Family or household recent history of acute rheumatic fever or rheumatic heart disease
• People with household overcrowding (>2 people/bedroom) or low socioeconomic status
• Migrants or refugees from low- or middle-income countries and their children

Additional factors that increase risk

• Previous residence in a high-risk setting
• Frequent or recent travel to a high-risk setting
• Age 5–20 years (peak years for developing acute rheumatic fever)

*T
 his refers to communities where the rates of acute rheumatic fever and rheumatic heart disease are high (for
example, an acute rheumatic fever incidence higher than 30/100,000 per year in those aged 5–14 years and a
rheumatic heart disease all-age prevalence higher than 2/1000).
Source: reproduced from reference 2 with permission

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ARTICLE Therapeutics for rheumatic fever and rheumatic heart disease

experience in endemic settings may have specialty Corticosteroids have reported benefits for severe or
knowledge of rheumatic fever, which should be refractory chorea and are therefore recommended if
sought to guide diagnosis and management. the response to carbamazepine or sodium valproate
is insufficient (Table 1).18 Intravenous immunoglobulin
Arthritis and plasmapheresis might be beneficial experimental
Naproxen and ibuprofen are the recommended immunotherapies for Sydenham chorea.2
first-line anti-inflammatory analgesics for rheumatic
arthritis (Table 1). Aspirin is now used second line due Antibiotics
to its less favourable safety profile. Initial high-dose As rheumatic fever is associated with group A
NSAID therapy, weaned after 1–2 weeks, is usual. streptococci, antibiotics play a key therapeutic role.
Proton pump inhibitor therapy for gastric protection S. pyogenes remains susceptible to penicillin, as it is
can be considered for patients requiring prolonged unable to genetically express resistance to penicillin.19
anti-inflammatory treatment.
Treatment and prevention of
The duration of treatment is guided by the disease streptococcal infection
severity, clinical response and concentrations of
The inciting streptococcal infection can be treated
inflammatory markers (C-reactive protein, erythrocyte
with the first dose of benzathine benzylpenicillin G
sedimentation rate). Most episodes of acute rheumatic
administered for ongoing secondary prophylaxis.
fever resolve within six weeks and 90% resolve within
Other options are presented in Table 1.
12 weeks. A rebound in inflammatory symptoms can
occur on ceasing treatment, requiring the drugs to be Secondary antibiotic prophylaxis is the mainstay of
re-introduced.2,13 treatment for acute rheumatic fever and rheumatic heart
disease globally to prevent recurrences of rheumatic
Carditis fever and thereby prevent cumulative valve damage
There is no targeted drug therapy available for cardiac with the development or progression of rheumatic heart
valve damage during the acute inflammatory stage. disease.20 The recommended regimen is intramuscular
Hydroxychloroquine has been used as a targeted injections of benzathine benzylpenicillin G every four
disease-modifying agent14 based on promising in weeks for a minimum of five years (if there is no
vitro findings,15 but clinical trial data are not yet cardiac involvement) or 10 years (if there is cardiac
available. For severe carditis, corticosteroids are involvement) after the last acute rheumatic fever episode
recommended (Table 1). However, meta-analyses or until 21 years of age, whichever is longer (Table 2).21
have suggested their lack of benefit in preventing The recurrence rates of acute rheumatic fever are
subsequent rheumatic heart disease,16,17 although significantly reduced by this regimen compared to a
the studies were mostly performed before the placebo22 or oral penicillin.23 Increasing adherence to
availability of echocardiography. Expert opinion benzathine benzylpenicillin G is associated with improved
recommends corticosteroids for carditis associated rheumatic fever outcomes.24 Regular oral penicillin is
with heart failure.2 If NSAIDs have been prescribed not as effective as benzathine benzylpenicillin G.25 This
for pericarditis or arthritis, these can be discontinued is potentially due to the serum penicillin concentrations
when corticosteroids are started, as corticosteroids achieved and problems with adherence.
provide effective relief of the manifestations of acute
Non-beta-lactam antibiotic options
rheumatic fever. Proton pump inhibitor therapy can be
An estimated 3.2% of people have an allergic reaction
considered for gastric protection in patients requiring
to penicillin and 0.2% have anaphylactic reactions.2,26
prolonged corticosteroid treatment. Screening for and
These people require alternative antibiotics.
the management of latent infections (e.g. hepatitis B,
strongyloidiasis, tuberculosis) are required before or Macrolide antibiotics (erythromycin, roxithromycin,
on starting immunosuppressive corticosteroid doses.2 azithromycin and clarithromycin) are favoured
alternatives in people with adverse reactions to beta-
Chorea lactams due to their tolerability and dosing regimen.
Pharmacotherapy is not needed for mild chorea. For They cover approximately 88% of S. pyogenes isolates
more severe cases, carbamazepine is recommended (Northern Territory Top End antibiogram data) due
as first-line treatment due to its safety profile, to the development of class resistance to macrolides
followed by sodium valproate (Table 1). A treatment and clindamycin in some isolates. The proportion of
response may not be observed for 1–2 weeks, and S. pyogenes resistant to macrolides in any region is
drugs may only reduce, not eliminate, chorea. related to local prescribing practices.4 As long as most
Treatment should be continued for 2–4 weeks after S. pyogenes isolates remain susceptible, macrolides
chorea has subsided, and then be withdrawn. are an acceptable second-line option.

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Table 1 Drugs used for rheumatic fever

Indication Drug options listed in order of preference Comment

Eradication of inciting 1. Benzathine benzylpenicillin G 1,200,000 units (child Streptococcal infection may not be evident by the
streptococcal infection <20 kg: 600,000 units, ≥20 kg: 1,200,000 units) time acute rheumatic fever manifests (e.g. cultures
intramuscularly, single dose often negative), but eradication therapy for possible
OR persisting streptococci is recommended.
Intramuscular penicillin is preferred as streptococcal
2. Phenoxymethylpenicillin 500 mg (child: 15 mg/kg up to eradication therapy due to better adherence and its
500 mg) orally, every 12 hours for 10 days subsequent ongoing use in secondary prophylaxis.
OR

3. For patients with penicillin hypersensitivity (non-severe): Between 3% and 30% of group A streptococcus
cefalexin 1 g (child: 25 mg/kg up to 1 g) orally, every isolates internationally are resistant to macrolide
12 hours for 10 days antibiotics (e.g. azithromycin).
OR

4. For patients with immediate penicillin hypersensitivity:

azithromycin 500 mg (child: 12 mg/kg up to 500 mg)
orally, daily for 5 days

Initial analgesia while awaiting Paracetamol 1000 mg (in children: 15 mg/kg) orally, every Initial analgesia is preferred during diagnostic
diagnostic confirmation: four hours as needed up to a maximum of 60 mg/kg/day uncertainty to avoid the masking effect that
• mild to moderate pain or 4000 mg/day anti-inflammatory use can have on migratory
joint symptoms, fever and concentrations of
• severe pain
inflammatory markers.

Tramadol immediate-release 50–100 mg (in children: Tramadol (or codeine) is usually avoided in children
1–2 mg/kg) orally, every four hours as needed up to a <12 years of age due to variable metabolism. Use
maximum of 400 mg/day only when strong analgesia is essential and cautious
monitoring is available.

Symptomatic management 1. Naproxen immediate-release 250–500 mg (in children: Naproxen may be safer than aspirin and convenient
of arthritis/arthralgia after 10–20 mg/kg/day) orally twice daily, up to a maximum due to twice-daily dosing and the availability of
confirmation of acute of 1250 mg daily oral suspension.
rheumatic fever diagnosis OR Ibuprofen is well tolerated and readily available,
but there are less data and experience with its use
2. Ibuprofen 200–400 mg (in children: 5–10 mg/kg) orally for acute rheumatic fever than those associated
three times daily, up to a maximum of 2400 mg daily with naproxen.
OR The dose of NSAIDs needed for acute rheumatic
fever is generally higher than the dose recommended
3. Aspirin 50–60 mg/kg/day orally, in 4–5 divided doses for other conditions; therefore, it may be appropriate
in adults and children. Dose can be escalated up to a to start at the higher dose range.
maximum of 80–100 mg/kg/day in 4–5 divided doses
Due to the rare possibility of Reye’s syndrome
in children, aspirin may need to be discontinued
during intercurrent acute viral illness; thus, influenza
vaccination is strongly recommended to reduce the
likelihood of this case.

Symptomatic management of 1. Carbamazepine 3.5–10 mg/kg per dose orally Treatment of Sydenham chorea should be
moderate to severe chorea twice daily considered if movements interfere substantially with
normal activities.
2. Sodium valproate 7.5–10 mg/kg per dose orally
twice daily

Symptomatic management of In addition to an anticonvulsant drug, consider adding

very severe chorea or chorea a corticosteroid:
paralytica • Prednisolone 1–2 mg/kg up to a maximum of 80 mg
orally once daily

Continued over page

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Table 1 Drugs used for rheumatic fever (continued)

Indication Drug options listed in order of preference Comment

Symptomatic management Paediatric dosing: Treatment of heart failure may be required
of carditis • Furosemide (frusemide) 1–2 mg/kg orally as a single for severe, acute carditis. Seek advice from a
dose, then 0.5–1 mg/kg (to a maximum of 6 mg/kg) specialist cardiologist.
orally every 6–24 hours
• Spironolactone 1–3 mg/kg (initially) up to 100 mg orally
in 1–3 divided doses daily. Round dose to a multiple of
6.25 mg (a quarter of a 25-mg tablet)

• Enalapril 0.1 mg/kg orally in 1 or 2 divided doses daily, The choice of ACE inhibitor will vary depending
increased gradually over 2 weeks to a maximum of on the clinical situation. Seek advice from a
1 mg/kg orally in 1 or 2 divided doses daily. Alternative specialist cardiologist.
ACE inhibitors: captopril, lisinopril

Adult dosing: The management of acute carditis follows the same

• Furosemide (frusemide) 20–40 mg orally or intravenously principles as those for the management of acute
as a single dose followed by 20–40 mg orally or heart failure. This table provides a guide to the initial
intravenously every 8–12 hours. Ongoing dose adjustment management of acute heart failure due to acute
is based on clinical progression and renal function. carditis in adults. Seeking advice from a specialist
cardiologist early is strongly recommended.
• Spironolactone may be added for patients with limited
or no response to loop diuretic; 12.5–200 mg orally
once daily with dose escalation based on clinical and
electrolyte responses.
• Nitrate therapy may be added for patients with limited
or no response to diuretic therapy and systolic blood
pressure greater than 90 mmHg. Intravenous or topical
glyceryl trinitrate may be used.
• ACE inhibitor therapy with perindopril or ramipril is
recommended in patients with moderate or severe left
ventricular systolic dysfunction, unless contraindicated.

Digoxin 15 micrograms/kg orally as a single dose, then Digoxin is rarely used for the treatment of acute
5 micrograms/kg after 6 hours, then 3–5 micrograms/kg carditis. Seek advice from a specialist cardiologist.
(in adults: 125–250 micrograms) orally, daily

Disease-modifying Prednisolone 1–2 mg/kg up to a maximum of 80 mg orally, Considered for use in selected cases of severe
(immunomodulatory) once daily carditis, despite meta-analyses in which the overall
treatments benefit was not evident.

Secondary prophylaxis 1. Benzathine benzylpenicillin G by deep intramuscular Every 28 days. †

injection 1,200,000 units (≥20 kg) or 600,000 units Every 21 days for selected groups. ‡
(<20 kg) *
OR

2. Phenoxymethylpenicillin (penicillin V) 250 mg orally Intramuscular penicillin is preferred due to

twice daily greater effectiveness in head-to-head trial and
OR better adherence.

3. For patients with penicillin hypersensitivity (non-severe)

or immediate penicillin hypersensitivity:
erythromycin 250 mg orally twice daily

NSAID non-steroidal anti-inflammatory drug

* For children weighing less than 10 kg, a dose of 600,000 units is still generally recommended, but seek paediatric advice for careful planning of the
secondary prophylaxis regimen.
† Patients on 28-day regimens can be recalled from 21 days to help ensure that injections are given by day 28.
‡ Benzathine benzylpenicillin G given every 21 days may be considered for:
• patients who have breakthrough acute rheumatic fever despite complete adherence to a 28-day regimen
• patients who are at a high risk of adverse consequences if acute rheumatic fever occurs (have severe rheumatic heart disease or a history of heart
valve surgery).
Source: modified from reference 2 with permission

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 Table 2 Recommended duration of secondary prophylaxis

Diagnosis Definition Duration of prophylaxis Conditions for Timing of echocardiography

ceasing prophylaxis * after cessation †

Possible acute rheumatic Incomplete features of acute 12 months (then reassess) No signs and symptoms of At 1 year
fever (without cardiac rheumatic fever with a normal acute rheumatic fever within the
involvement) echocardiogram and normal ECG ‡ previous 12 months
throughout acute rheumatic fever Normal echocardiogram
episodes

Probable acute rheumatic Highly suspected acute rheumatic Minimum of 5 years after the most recent episode of No probable or definite acute At 1, 3 and 5 years
fever (without cardiac fever with a normal echocardiogram probable acute rheumatic fever, or until 21 years of age rheumatic fever within the
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involvement) (whichever is longer) previous 5 years

Normal echocardiogram

Definite acute rheumatic Acute rheumatic fever with a normal Minimum of 5 years after the most recent episode No probable or definite acute At 1, 3 and 5 years
fever (without cardiac echocardiogram and normal ECG ‡ of acute rheumatic fever, or until 21 years of age rheumatic fever within the
involvement) throughout acute rheumatic fever (whichever is longer) previous 5 years
episodes Normal echocardiogram

Definite acute rheumatic Acute rheumatic fever with According to the severity of rheumatic heart disease (borderline, mild, moderate, severe)
fever (with cardiac carditis or rheumatic heart
involvement) disease on echocardiography, or
with atrioventricular conduction
abnormality on ECG ‡ during acute
rheumatic fever episodes

Borderline rheumatic Borderline rheumatic heart disease In a high-risk setting: minimum of 2 years following the No probable or definite acute Medical review and repeat
heart disease (in people on echocardiography without diagnosis of borderline rheumatic heart disease rheumatic fever within the echocardiogram at 1–2 years
≤20 years of age only) a documented history of acute If borderline rheumatic heart disease is still present previous 10 years after diagnosis, and 1–2 years
rheumatic fever at 2 years, continue for another 2 years and reassess. Normalisation of echocardiogram after stopping secondary
Seek specialist input § after a minimum of 2 years of prophylaxis
follow-up

Mild rheumatic heart Mild rheumatic heart disease on If there is a documented history of acute rheumatic No probable or definite acute At 1, 3 and 5 years
disease # echocardiography or atrioventricular fever: minimum of 10 years after the most recent rheumatic fever within the previous
conduction abnormality on ECG ‡ episode of acute rheumatic fever, or until 21 years of 10 years and no progression of
during acute rheumatic fever age (whichever is longer) rheumatic heart disease
episodes If there is NO documented history of acute rheumatic Stable echocardiographic features
fever and age is <35 years: ¶ minimum of 5 years for 2 years
following the diagnosis of rheumatic heart disease or
until 21 years of age (whichever is longer)

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Table 2 Recommended duration of secondary prophylaxis (continued)
ARTICLE
Diagnosis Definition Duration of prophylaxis Conditions for Timing of echocardiography
ceasing prophylaxis * after cessation †
Moderate rheumatic Moderate rheumatic heart disease If there is a documented history of acute rheumatic No probable or definite acute Initially every 12 months
heart disease # ** on echocardiography fever: minimum of 10 years after the most recent rheumatic fever within the
episode of acute rheumatic fever or until 35 years of previous 10 years
age (whichever is longer) Stable echocardiographic features
If there is no documented history of acute rheumatic for 2 years
fever and age is <35 years: ¶ minimum of 5 years
following the diagnosis of rheumatic heart disease or
until 35 years of age (whichever is longer)

Severe rheumatic Severe rheumatic heart disease If there is a documented history of acute rheumatic Stable valvular disease/ Initially every 6 months
heart disease ** †† on echocardiography fever: minimum of 10 years after the most recent cardiac function on serial
OR episode of acute rheumatic fever or until 40 years of echocardiography for 3 years
age (whichever is longer) OR
Previous valve repair or prosthetic
valve replacement If there is no documented history of acute rheumatic Patient or family preference to
fever: ‡‡ minimum of 5 years following the diagnosis cease due to advancing age or
of rheumatic heart disease or until 40 years of age end-of-life care
(whichever is longer)

Full text free online at nps.org.au/australian-prescriber

* All people receiving secondary prophylaxis require a comprehensive clinical assessment and echocardiogram before cessation. Risk factors including future exposure to environments with a high
burden of group A streptococcus must be considered.
† Echocardiography may be more frequently performed based on the clinical status and specialist review.
‡ ‘Normal ECG’ indicates that there is no atrioventricular conduction abnormality during the acute rheumatic fever episode, including first-degree heart block, second-degree heart block, third-degree
(complete) heart block or an accelerated junctional rhythm.
§ An update in March 2022 recommends secondary prophylaxis for people ≤20 years of age living in high-risk settings without a documented history of acute rheumatic fever but who have an
echocardiogram showing borderline rheumatic heart disease. 21
# Prophylaxis may be considered for longer in women considering pregnancy who live in high-risk circumstances for acute rheumatic fever.
¶ If diagnosed with mild or moderate rheumatic heart disease and aged ≥35 years (without acute rheumatic fever), secondary prophylaxis is not required.
Therapeutics for rheumatic fever and rheumatic heart disease

** Rarely, moderate or severe rheumatic heart disease may improve on echocardiography without valve surgery. In these cases, the conditions for ceasing prophylaxis can change to follow the most
recent severity category. For instance, if moderate rheumatic heart disease improves to mild on echocardiography, recommendations for mild rheumatic heart disease can then be followed.
†† The risk of acute rheumatic fever recurrence is low in people ≥40 years of age; however, lifelong secondary prophylaxis is usually recommended for patients who have had, or are likely to need, heart
valve surgery.
‡‡ If a person is diagnosed with severe rheumatic heart disease at ≥40 years of age (without acute rheumatic fever), specialist input is required to determine the need for secondary prophylaxis.
Source: reproduced from reference 2 with permission
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For non-severe penicillin hypersensitivity, use disease undergoing high-risk dental or other surgical
cefalexin to treat the inciting streptococcal infection procedures.1,27 These procedures are listed in
and erythromycin for secondary prophylaxis. For Therapeutic Guidelines: Antibiotic.28
immediate penicillin hypersensitivity, use azithromycin Amoxicillin is the recommended first-line drug for
to treat the inciting streptococcal infection and endocarditis prophylaxis for certain dental procedures
erythromycin for secondary prophylaxis (Table 1). in patients with specified cardiac conditions
including rheumatic heart disease, even in those
Management of rheumatic
heart disease receiving benzathine benzylpenicillin G for secondary
prophylaxis (Table 3). However, if a patient has
Secondary antibiotic prophylaxis is the only
recently had a course of treatment with penicillin,
treatment confirmed to be associated with a long-
amoxicillin or another beta-lactam (providing higher
term reduction in the severity of rheumatic heart
antibiotic concentrations than prophylactic doses),
disease. Patients with moderate to severe rheumatic
clindamycin is the recommended first-line drug. This is
heart disease require cardiology services and regular
because the treatment course may have reduced the
echocardiographic follow-up.2 Women with rheumatic
amoxicillin susceptibility of viridans streptococci, which
heart disease who are pregnant or of childbearing age
are commensal oral organisms that can be mobilised
require pre-conception counselling and specialist care.
into the bloodstream following dental procedures.
Comprehensive guidance on medical and surgical
management is detailed in the 2020 Australian
Guideline for Acute Rheumatic Fever and Rheumatic Conclusion
Heart Disease.2
Practitioners in Australia might encounter cases of
Prevention of infective endocarditis acute rheumatic fever and rheumatic heart disease.
Rheumatic heart disease poses a risk for infective Those practising in high-burden settings, especially
endocarditis. Certain dental and other invasive remote Aboriginal and Torres Strait Islander
surgical procedures can cause transient bacteraemia, communities, need a low threshold for suspecting
leading to infection of damaged or prosthetic valves. these conditions and familiarity with guidelines
Guidelines have oscillated on antibiotic prophylaxis and resources. Rheumatic Heart Disease Control
for infective endocarditis. The weight of evidence Programs and Rheumatic Heart Disease Australia
now favours antibiotic use for infective endocarditis can assist practitioners, address clinical queries and
prophylaxis in all patients with rheumatic heart provide resources.

Table 3 O
 ral prophylactic antibiotics for infective endocarditis in certain
dental procedures*

Indication Drug Time before

the procedure
For endocarditis prophylaxis Amoxicillin 2 g 60 minutes
(in children: 50 mg/kg up to 2 g)

For patients with delayed non-severe hypersensitivity Cefalexin 2 g 60 minutes

to penicillins, cefalexin can be used in most cases (in children: 50 mg/kg up to 2 g)

For patients with immediate (severe or non-severe) Clindamycin ‡ 600 mg 60–120 minutes
or delayed severe hypersensitivity to penicillins (in children: 20 mg/kg up to 600 mg)

For patients who have recently received a treatment- Clindamycin ‡ 600 mg 60–120 minutes
dose course of a beta-lactam antibiotic (in children: 20 mg/kg up to 600 mg)

* See Therapeutic Guidelines: Antibiotic, Box 2.13 ‘Procedures for which endocarditis prophylaxis is recommended
for patients with a cardiac condition’28 for a list of the dental procedures for which endocarditis prophylaxis is
recommended in patients with rheumatic heart disease. For endocarditis prophylaxis for other procedures, see eTG28
† See Therapeutic Guidelines: ‘Endocarditis prophylaxis regimens for dental procedures’ for details on intramuscular
or intravenous options28
‡ There is some evidence to suggest that moxifloxacin may be used as an alternative to clindamycin in patients with
immediate (severe) or non-severe or delayed hypersensitivity to penicillins, but this has not been validated.
Source: modified with permission from reference 2, which includes intravenous and intramuscular options.

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