Table 2. Drugs used in acute rheumatic fever .
| DURING ACUTE RHEUMATIC FEVER EPISODE | ||
|---|---|---|
| Indication | Drug (choice) | Comment |
| Eradication of inciting streptococcal infection | 1. Benzathine penicillin G 900 mg (child 3–6 kg: 225 mg, 6–10 kg: 337.5 mg, 10–15 kg: 450 mg, 15–20 kg: 675 mg) given intramuscularly as a single dose* OR |
Streptococcal infection may not be evident by the time acute rheumatic fever manifests (e.g. cultures often negative), but eradication therapy for possible persisting streptococci is still recommended. Intramuscular penicillin is preferred due to better adherence. |
| 2. Penicillin hypersensitivity: cephalexin 1 g (child: 25 mg/kg up to 1 g) orally, 12-hourly for 10 days | ||
| 3. Immediate penicillin hypersensitivity: azithromycin 500 mg (child: 12 mg/kg up to 500 mg) orally daily for 5 days | ||
| Initial analgesia while awaiting diagnostic confirmation | 1. Paracetamol 15 mg/kg orally, 4-hourly up to a maximum of 60 mg/kg/day (not more than 4 g daily) | Preferred initial analgesia during diagnostic uncertainty, to avoid the masking effect anti-inflammatory use can have on migratory joint symptoms. |
| Symptomatic management of arthritis or arthralgia | 1. Aspirin 50–60 mg/kg/day up to a maximum of 80–100 mg/kg/day in four or five divided doses | Due to the rare possibility of Reye’s syndrome in children, aspirin may need to be ceased during an intercurrent acute viral illness, and an influenza vaccination provided if aspirin is used during influenza season. |
| 2. Naproxen (10–20 mg/kg/day) orally, twice-daily3,4 | Naproxen may be safer than aspirin, and convenient due to twice-daily dosing and the availability of an oral suspension. However, there is less experience with naproxen in acute rheumatic fever. | |
| SECONDARY PROPHYLAXIS | ||
|---|---|---|
| Indication | Drug | Comment |
| Prevention of subsequent streptococcal infections16 | 1. Benzathine penicillin G 900 mg (child <20 kg: 450 mg)* intramuscularly as a single dose once every 21 or 28 days | Rare breakthrough acute rheumatic fever cases occur despite regular dosing, due to waning penicillin concentrations towards the end of the 28-day period. Therefore an injection every 3 weeks is prescribed for some individuals (generally <2% of people with acute rheumatic fever). Oral penicillin is less effective and is not recommended except in exceptional circumstances (e.g. temporary inability to access injection while travelling). |
| 2. Immediate penicillin hypersensitivity: erythromycin 250 mg (child: 10 mg/kg up to 250 mg) orally 12-hourly | ||
| ENDOCARDITIS PROPHYLAXIS IN ESTABLISHED RHEUMATIC HEART DISEASE | ||
|---|---|---|
| Indication | Drug | Comment |
| Individuals having high-risk dental or respiratory procedures† | 1. Ampicillin 2 g (child: 50 mg/kg up to 2 g) intravenously within 60 min (ideally 15–30 min) before the procedure 2. Penicillin hypersensitivity: cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously within 60 min before the procedure 3. Immediate penicillin hypersensitivity: clindamycin 600 mg (child: 20 mg/kg) intravenously within 60 min before the procedure |
Note intravenous ampicillin and clindamycin can be substituted with appropriately timed oral dosing of amoxycillin or clindamycin respectively. |
| Individuals having high-risk genitourinary, gastrointestinal or infected skin or soft tissue procedures | 1. Ampicillin 2 g (child: 50 mg/kg up to 2 g) intravenously within 60 min (ideally 15–30 min) before the procedure | Note the drugs listed here which provide Gram positive cover are given in addition to any standard prophylactic recommendation required for that procedure (e.g. in combination with metronidazole plus cephazolin or gentamicin for colorectal surgery). |
| 2. Penicillin hypersensitivity or immediate hypersensitivity: teicoplanin 400 mg (child: 10 mg/kg up to 400 mg) intravenously within 60 min (ideally 15–30 min) before the procedure | Note vancomycin can be used instead of teicoplanin if the timing of administration can be appropriately arranged. | |