Table 2.

The main features of the updated guidelines.

Item	Previous Sudan guidelines (2017)	Updated guidelines (2022)	Rationale/evidence
ARF diagnosis	Modified Jones Criteria	Simplified criteria (arthritis, carditis, chorea)	- ARF could be transient - Evidence of high prevalence of subclinical carditis - Need to have a low threshold in highly endemic areas - Complexity of Jones Criteria Class I-B
ARF treatment	- BPG prophylaxis only after confirmation of diagnosis by Jones Criteria - Aspirin as anti-inflammatory	- BPG to all patients with arthritis, carditis, or chorea at primary care level - Ibuprofen as first-line treatment	- BPG can prevent progression of subclinical carditis - Ibuprofen is as effective and safer than aspirin Class I-B
Skin infection	Not included	Diagnosis and treatment of streptococcal skin infection is included as primary prevention of ARF	Evidence that skin infection can contribute to ARF Class II-B
Benzathine penicillin administration	No special precautions for patients with severe valve disease No sensitivity testing	- Not to be given for patients with severe uncontrolled heart failure - To give oral fluid before BPG injection - Graded oral challenge for patients with suspected mild allergy	Evidence that there are fatal non-allergic reactions to BPG in patients with severe heart failure Class II-A

Green: Class I, Yellow, Class II-A.

Orange: Class II-B.