Materiały źródłowe

• #1 Acute rheumatic fever: Treatment and prevention – UpToDate

  https://www.uptodate.com/contents/acute-rheumatic-fever-treatment-and-prevention/print

  Acute rheumatic fever (ARF) is a nonsuppurative complication of pharyngeal infection with group A Streptococcus (GAS). Signs and symptoms of ARF develop two to three weeks following pharyngitis and include arthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum. […] Treatment and secondary prevention of rheumatic fever are reviewed here. […] Treatment of ARF consists of antibiotic therapy, antiinflammatory therapy, heart failure management, and commencement of ongoing care (secondary prevention and provision of education). […] Hospitalization is advisable for optimal management of ARF, especially for an initial episode, so that all tests can be completed, response to therapy can be observed, and long-term preventative measures can be started with appropriate education for the patient and their caregivers. […] The six major goals of treatment are: Eradication of group A beta-hemolytic Streptococcus (GAS).

• #1 Primary prevention of acute rheumatic fever

  https://www1.racgp.org.au/ajgp/2021/may/primary-prevention-of-acute-rheumatic-fever

  Acute rheumatic fever (ARF) is an abnormal immune reaction following Streptococcus pyogenes (Strep A) infection of the throat, and likely the skin. Primary prevention is the prompt and appropriate antibiotic treatment of Strep A infection, and it can reduce the risk of developing ARF and subsequent rheumatic heart disease. […] People at increased risk of ARF should be offered empirical antibiotic treatment of Strep A infections to reduce this risk. […] Primary prevention involves the identification of Strep A infections and delivery of appropriate antibiotic treatment to prevent ARF (as distinct from antibiotic treatment to shorten the duration of infection, heal the sores or provide symptomatic relief). The evidence that treatment of Strep A throat infections can prevent ARF is strong, albeit based on historic studies.

• #1 Primary prevention of acute rheumatic fever

  https://www1.racgp.org.au/ajgp/2021/may/primary-prevention-of-acute-rheumatic-fever

  Prompt treatment with oral penicillin is reported to reduce the attack rate of ARF following Strep A throat infection by approximately 70%, increasing to 80% if a single intramuscular injection of benzathine benzylpenicillin G (BPG) is given. […] There is no empirical evidence that antibiotic treatment of Strep A skin infections has the same effect in reducing ARF risk. […] People who may be at high risk of ARF require primary prevention antibiotic treatment for sore throat. […] The devastating consequences of RHD can be prevented by primary prevention for people at greatest risk of ARF. […] Development of ARF can be prevented by early detection and appropriate antibiotic treatment of sore throats and skin sores for higher-risk groups.

• #1 AHA Guidelines on Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/0201/p346.html

  Although the overall incidence of acute rheumatic fever and rheumatic heart disease is low in most areas of the United States, they are the leading causes of cardiovascular death during the first five decades of life in developing countries. This disparity serves as a reminder of the importance of continued vigilance to prevent these diseases. The American Heart Association (AHA) recently updated its recommendations on the prevention of rheumatic fever. […] Primary prevention of rheumatic fever requires adequate therapy for GAS pharyngitis. In selecting a treatment regimen, physicians should consider bacteriologic and clinical effectiveness, ease of adherence to the recommended regimen (i.e., dosing frequency, duration of therapy, and palatability), cost, spectrum of activity of the selected agent, and potential adverse effects.

• #1 Acute Rheumatic Fever | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540006/all/Acute_Rheumatic_Fever

  Prevention […] See GAS and pharyngitis modules for details. […] Duration rather than dose is believed important for GAS eradication from the oropharynx. […] Parenteral: PCN G benzathine 1.2 million units IM (single dose) […] If wt. 60lb dose 600,000 million units IM. […] Oral: PCN VK 250mg PO three times a day (children), 500mg PO three times a day (adolescents, adults) for FULL 10 days. […] Amoxicillin liquid is often preferred w/ young children, dose 25-50 mg/kg/day PO q8h for FULL 10d. […] PCN allergic: erythromycin 40mg/kg/d 2-4 times daily (max. 1g/d) for FULL 10 days. […] Treatment of Group A strep throat even 9d after onset is still effective in the prevention of ARF. […] […] […] Secondary prevention ARF […] To prevent recurrent attacks of GAS infection and therefore ARF leading to RHD.

• #1 Rheumatic Fever: Causes, Symptoms (Rash) & Treatment

  https://my.clevelandclinic.org/health/diseases/16616-rheumatic-fever

  Treating strep throat and scarlet fever early is essential. It can prevent rheumatic fever. […] If your child has strep throat or scarlet fever, make sure you follow their providers instructions carefully. Your child needs to finish the full course of antibiotics, even if they feel better. Otherwise, the infection may not go away and may make your child more prone to rheumatic fever. […] If your child’s been diagnosed with rheumatic fever, their provider may prescribe a long-term antibiotic (monthly injections of penicillin). This can help prevent future bouts of strep throat and prevent recurrences of rheumatic fever. […] If theyve had rheumatic fever, their provider may recommend they take antibiotics for years or possibly throughout their life. This treatment is called antibiotic prophylaxis. It can prevent another strep infection and keep rheumatic fever from coming back.

• #1 Guidelines for the secondary prevention of rheumatic heart disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6372451/

  Rheumatic fever and rheumatic heart disease can be prevented with appropriate antibiotics administration to prevent the progression of valve damage. […] Generally, primary prevention of RF using the appropriate antibiotics to treat preceding Streptococcus pyogenes infection is considered the most effective method for preventing rheumatic heart disease. Moreover, RF can be prevented and controlled with regular antibiotics by inhibiting the risk for further S. pyogenes infections and causing progression of valve damage. Thus, heart valve surgery to repair or replace damaged heart valves can be prevented or delayed by using secondary prophylaxis antibiotics. […] All patients who have had rheumatic carditis, with or without valvular disease, are at high risk for RHD recurrence should receive long-term antibiotics therapy as secondary prevention. Prophylactic antibiotic therapy should be continued even after valve surgery, irrespective of the valve location or type (including mechanical and biological valves replacement), since these patients remain at risk for recurrence of RHD for the involved valve or other valves.

• #1 AHA Guidelines on Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/0201/p346.html

  Continuous prophylaxis is recommended in patients with well-documented histories of rheumatic fever and in those with evidence of rheumatic heart disease. Prophylaxis should be initiated as soon as acute rheumatic fever or rheumatic heart disease is diagnosed. […] Continuous antimicrobial prophylaxis provides the most effective protection from recurrences of rheumatic fever. […] In the United States, an injection of penicillin G benzathine every four weeks is the recommended prophylactic regimen for secondary prevention in most circumstances. […] Successful oral prophylaxis depends on patient adherence to the prescribed regimen. Patients should be given careful, repeated instructions about the importance of compliance to the dosing regimen.

• #1 Acute Rheumatic Fever Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333103-treatment

  Prevention of ARF has been successful in developed societies. The recommended approach can be divided into primary and secondary prevention. Primary prevention involves eradication of Streptococcus from the pharynx, which generally entails administering a single intramuscular injection of benzathine benzylpenicillin. […] For secondary prevention, the American Heart Association (AHA) Committee on Acute Rheumatic Fever recommends a regimen consisting of benzathine benzylpenicillin at 1.2 million units intramuscularly every 4 weeks. However, in high-risk situations, administration every 3 weeks is justified and advised. High-risk situations include patients with heart disease who are at risk of repetitive exposure. […] Oral prophylaxis, which is less reliable, consists of phenoxymethylpenicillin (penicillin V) or sulfadiazine. These can be used in compliant patients. If penicillin allergy is suspected, oral cephalosporins should be used.

• #1 Do long-term antibiotics help to reduce rheumatic fever recurrence and progression of rheumatic heart disease? | Cochrane

  https://www.cochrane.org/CD015779/CENTRALED_do-long-term-antibiotics-help-reduce-rheumatic-fever-recurrence-and-progression-rheumatic-heart

  Pooled meta-analysis of six RCTs provides moderate-certainty evidence that antibiotics overall (oral or intramuscular) probably reduce the risk of recurrence of rheumatic fever substantially (0.7% versus 1.7%, respectively) (risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.69; 1721 participants). […] People with early or mild RHD likely have the greatest capacity to benefit from intramuscular antibiotic prophylaxis (8.1%) compared to no antibiotics (0.7%) (RR 0.09, 95% CI 0.03 to 0.29; 1 study, 818 participants; moderate-certainty evidence). […] Antibiotics may not affect mortality in people with late-stage RHD (RR 1.23, 95% CI 0.78 to 1.94; 1 study, 994 participants; low-certainty evidence). […] Pooled analysis of two RCTs showed that prophylactic intramuscular benzathine benzylpenicillin likely reduces recurrence of rheumatic fever substantially when compared to oral antibiotics (0.1% versus 1%, respectively) (RR 0.07, 95% CI 0.02 to 0.26; 395 participants; moderate-certainty evidence).

• #1 Acute Rheumatic Fever Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333103-treatment

  Although no consensus on the required duration of antibacterial prophylaxis has been reached, the AHA recommends continuing prophylaxis for at least 10 years after the last episode of rheumatic fever or until patients are well into adulthood. For those with heart disease who are at risk of repetitive exposures, prophylaxis should be continued for a longer duration, probably indefinitely. However, discontinuing prophylaxis may be reasonable in patients in their third decade of life in whom more than 5 years have passed since their last attack and who are free from rheumatic heart disease. […] The principles of treatment include the following: The risk of rheumatic fever recurrence is greatest during the first 3-5 years following the attack. Prophylaxis must continue indefinitely in patients with established heart disease or in those frequently exposed to streptococci. Treatment for an indefinite period is required for patients with frequent exposure to streptococci or for those who are difficult to monitor.

• #1

  https://journals.lww.com/jfmpc/fulltext/2020/09030/compliance_to_the_secondary_prophylaxis_and.25.aspx

  Rheumatic heart disease is a preventable problem and regular secondary prophylaxis and proper awareness about this disease among common people may reduce the burden of this disease in any region. […] Approximately half of the participants of this study were non-compliant to the regular secondary prophylaxis of rheumatic heart disease and most of them had poor awareness of this disease. Ensuring regular secondary prophylaxis and improving awareness to Rheumatic heart disease among common people may reduce its prevalence in regions with significant burden of Rheumatic heart disease. […] Regular secondary prophylaxis and awareness of RHD are some of the recognized factors which can reduce the burden of this disease, in any region. Noncompliance to the secondary prophylaxis is a significant risk factor for the recurrences of acute rheumatic fever.

• #1 Sharing success – understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-016-0344-x

  Rheumatic fever (RF) and rheumatic heart disease (RHD) cause considerable morbidity and mortality amongst Australian Aboriginal and Torres Strait Islander populations. Secondary antibiotic prophylaxis in the form of 4-weekly benzathine penicillin injections is the mainstay of control programs. Evidence suggests, however, that delivery rates of such prophylaxis are poor. […] Deficits in registration and recall systems and pain attributed to injections were identified as barriers to secondary prophylaxis uptake. […] Enablers of secondary prophylaxis uptake included positive patient-healthcare provider relationships, supporting patient autonomy, education of patients, care givers and healthcare providers, and community-based service delivery. […] Secondary prophylaxis is a core component of RF/RHD management strategies.

• #1 Acute rheumatic fever: Treatment and prevention – UpToDate

  https://www.uptodate.com/contents/acute-rheumatic-fever-treatment-and-prevention

  Acute rheumatic fever: Treatment and prevention […] Treatment and secondary prevention of rheumatic fever are reviewed here. […] Overview—Treatment of ARF consists of antibiotic therapy, antiinflammatory therapy, heart failure management, and commencement of ongoing care (secondary prevention and provision of education). […] Goals of treatment—The six major goals of treatment are: […] Eradication of group A beta-hemolytic Streptococcus (GAS). […] Choice of antibiotic agent for treatment and prophylaxis of acute rheumatic fever. […] Secondary prophylaxis for rheumatic fever – Duration of therapy.

• #1 Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012468

  Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. […] Secondary prevention is the cornerstone of WHO-endorsed ARF and RHD control programmes and has been argued to be the most cost-effective strategy for reducing RHD mortality. […] Despite the widespread acceptance of secondary prevention, several critical scientific and practical questions remain unresolved. […] We need a better understanding of RHD epidemiology to guide programmes, policies and practice. […] We need better strategies to find and diagnose people affected by ARF and RHD. […] We urgently need better tools to manage ARF and slow the progression of RHD.

• #1

  https://www.who.int/news-room/fact-sheets/detail/rheumatic-heart-disease

  For countries where rheumatic heart disease is endemic, the main strategies for prevention, control and elimination include improving standards of living; expanding access to screening and appropriate care for people with suspected or confirmed streptococcal infections and RF/RHD and treatment of RHD complications with medications; ensuring a consistent supply of quality-assured antibiotics for primary and secondary prevention; and planning, developing and implementing feasible programmes for prevention and control of rheumatic heart disease, supported by adequate monitoring and surveillance, as an integrated component of national health systems responses.

• #2 AHA Guidelines on Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis | AAFP

  https://www.aafp.org/pubs/afp/issues/2010/0201/p346.html

  Although the overall incidence of acute rheumatic fever and rheumatic heart disease is low in most areas of the United States, they are the leading causes of cardiovascular death during the first five decades of life in developing countries. This disparity serves as a reminder of the importance of continued vigilance to prevent these diseases. The American Heart Association (AHA) recently updated its recommendations on the prevention of rheumatic fever. […] Primary prevention of rheumatic fever requires adequate therapy for GAS pharyngitis. In selecting a treatment regimen, physicians should consider bacteriologic and clinical effectiveness, ease of adherence to the recommended regimen (i.e., dosing frequency, duration of therapy, and palatability), cost, spectrum of activity of the selected agent, and potential adverse effects.

• #2 Primary Prevention | Rheumatic Heart Disease Australia

  https://www.rhdaustralia.org.au/primary-prevention

  Primary prevention of acute rheumatic fever (ARF) interrupts the link between group A streptococcal (Strep A) infections and the autoimmune response to the infection. If given early in the infection, antibiotics interrupt the autoimmune response and ARF does not occur. This requires identifying and treating Strep A infections of the throat and skin in people at high risk of ARF. […] Treatment for Strep A throat infections is either one intramuscular benzathine benzylpenicillin injection or a course of antibiotic tablets/syrup. Treatment for Strep A associated skin infection is either antibiotic tablets/syrup or one intramuscular benzathine benzylpenicillin injection. […] Antibiotics for Strep A throat infections in people at high risk of ARF can reduce development of ARF by up to two-thirds.

• #2 Acute Rheumatic Fever | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540006/all/Acute_Rheumatic_Fever

  Prevention […] See GAS and pharyngitis modules for details. […] Duration rather than dose is believed important for GAS eradication from the oropharynx. […] Parenteral: PCN G benzathine 1.2 million units IM (single dose) […] If wt. 60lb dose 600,000 million units IM. […] Oral: PCN VK 250mg PO three times a day (children), 500mg PO three times a day (adolescents, adults) for FULL 10 days. […] Amoxicillin liquid is often preferred w/ young children, dose 25-50 mg/kg/day PO q8h for FULL 10d. […] PCN allergic: erythromycin 40mg/kg/d 2-4 times daily (max. 1g/d) for FULL 10 days. […] Treatment of Group A strep throat even 9d after onset is still effective in the prevention of ARF. […] […] […] Secondary prevention ARF […] To prevent recurrent attacks of GAS infection and therefore ARF leading to RHD.

• #2 Rheumatic Fever (ARF)

  https://www.utmb.edu/Pedi_Ed/CoreV2/CardiologyPart1/CardiologyPart116.html

  Prevention of rheumatic fever requires adequate therapy for GAS pharyngitis. In selecting a regimen for the treatment of GAS pharyngitis, physicians should consider various factors, including bacteriologic and clinical efficacy, ease of adherence to the recommended regimen (frequency of daily administration, duration of therapy, and palatability), cost, spectrum of activity of the selected agent, and the potential side effects. […] Patients with a documented history of ARF should receive antibiotic prophylaxis until the age of 21 or for a minimum of five years if there is no cardiac involvement. Patients with valvular abnormalities should receive lifetime prophylaxis. Prophylaxis consists of monthly injections of benzathine penicillin; alternatively, twice daily oral penicillin V may be used. Oral sulfadiazine may be used for patients with penicillin allergy, but it is not as effective as penicillin.

• #2 Acute Rheumatic Fever Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333103-treatment

  Prevention of ARF has been successful in developed societies. The recommended approach can be divided into primary and secondary prevention. Primary prevention involves eradication of Streptococcus from the pharynx, which generally entails administering a single intramuscular injection of benzathine benzylpenicillin. […] For secondary prevention, the American Heart Association (AHA) Committee on Acute Rheumatic Fever recommends a regimen consisting of benzathine benzylpenicillin at 1.2 million units intramuscularly every 4 weeks. However, in high-risk situations, administration every 3 weeks is justified and advised. High-risk situations include patients with heart disease who are at risk of repetitive exposure. […] Oral prophylaxis, which is less reliable, consists of phenoxymethylpenicillin (penicillin V) or sulfadiazine. These can be used in compliant patients. If penicillin allergy is suspected, oral cephalosporins should be used.

• #2 Rheumatic fever – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/rheumatic-fever/symptoms-causes/syc-20354588

  Rheumatic fever can happen after a throat infection from group A streptococcus bacteria, also called strep bacteria. The bacteria cause strep throat and scarlet fever. Improperly treated strep throat or scarlet fever infections cause rheumatic fever. […] There’s little chance of getting rheumatic fever when strep throat is treated right away with antibiotics. It’s important to finish all of the medicine. […] The best way to prevent rheumatic fever is to treat strep throat infections or scarlet fever right away. It’s also important to finish all of the prescribed antibiotics as directed.

• #2 Clinical Update – Secondary Prevention of ARF | Rheumatic Heart Disease Australia

  https://www.rhdaustralia.org.au/news/clinical-update-secondary-prevention-arf

  The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition) contains clinical information based on national and international best practice. […] There are several opportunities for intervention – prevention along the ARF-RHD disease pathway; including primordial prevention of group A streptococcal (Strep A) infections, primary prevention of ARF, secondary prevention of ARF, and tertiary prevention of complications associated with RHD. […] Secondary prophylaxis for acute rheumatic fever (ARF) is the consistent and regular administration of antibiotics to prevent group A beta-haemolytic streptococcus (Strep A) infections and recurrent ARF. […] Regular antibiotic prophylaxis is recommended for people who are highly suspected or confirmed to have ARF, and for people who have RHD.

• #2 Guidelines for the secondary prevention of rheumatic heart disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6372451/

  Secondary antibiotic prophylaxis is used to reduce the acquisition of new group A streptococcal strains that might induce repeated or chronic and acute rheumatic fever attacks, and is a major determinant of cardiac outcome. […] These guidelines outline practical recommendations for secondary prevention of RHD. We also would like to stress on the fact that primary prevention of rheumatic fever is the optimal approach.

• #2 Therapeutics for rheumatic fever and heart disease

  https://australianprescriber.tg.org.au/articles/therapeutics-for-rheumatic-fever-and-rheumatic-heart-disease.html

  The goals of acute rheumatic fever therapy are to relieve symptoms, mitigate cardiac valve damage and eradicate streptococcal infection. Preventing future recurrences requires long-term secondary antibiotic prophylaxis and ongoing prevention of Streptococcus pyogenes (group A streptococcus) infections. […] The recommended regimen for secondary prophylaxis comprises benzathine benzylpenicillin G intramuscular injections every four weeks. For patients with non-severe or immediate penicillin hypersensitivity, use erythromycin orally twice daily. […] Secondary antibiotic prophylaxis is the mainstay of treatment for acute rheumatic fever and rheumatic heart disease globally to prevent recurrences of rheumatic fever and thereby prevent cumulative valve damage with the development or progression of rheumatic heart disease.

• #2 Acute Rheumatic Fever | Johns Hopkins ABX Guide

  https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540006/all/Acute_Rheumatic_Fever

  Preferred: benzathine PCN G 1.2 million units IM q4wk (or q3wk if high risk) […] Alternative: erythromycin 250mg PO twice-daily, only if truly PCN allergic […] Consider beta-lactam desensitization. […] Oral PCN Vk use is discouraged. […] Prevention is viewed as key to reducing risks of RHD since there is no medical management, only ultimately surgical intervention by valve replacement. […] A recent study in Uganda suggested significant effectiveness of monthly benzathine PCN G x 2 years in 5-17-year-olds at risk for RHD progression. […] Duration of secondary prevention uncertain, many discontinue by late teenage/early adult years OR 10 yrs after the last attack if an adult. […] Oral antibiotics are inferior to injectables for prophylaxis. Oral therapy is only recommended if the patient is truly hypersensitive to penicillins. […] Though effective, secondary prevention is often hampered by compliance issues (long time-frame, painful infections).

• #2 Acute Rheumatic Fever Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333103-treatment

  In underdeveloped countries, prophylaxis should be continued as follows: Continue for 5 years after the first attack, Continue indefinitely in patients with established heart disease, Continue indefinitely in patients who are frequently exposed to streptococci and are difficult to monitor. […] The decision to withdraw antibacterial treatment should be individualized after carefully assessing the risk of repetitive exposures.

• #2

  https://journals.lww.com/ijpam/fulltext/2017/04010/guidelines_for_the_secondary_prevention_of.8.aspx

  Rheumatic fever and rheumatic heart disease can be prevented with appropriate antibiotics administration to prevent the progression of valve damage. […] Generally, primary prevention of RF using the appropriate antibiotics to treat preceding Streptococcus pyogenes infection is considered the most effective method for preventing rheumatic heart disease, Moreover, RF can be prevented and controlled with regular antibiotics by inhibiting the risk for further S. pyogenes infections and causing progression of valve damage, Thus, heart valve surgery to repair or replace damaged heart valves can be prevented or delayed by using secondary prophylaxis antibiotics. […] All patients who have had rheumatic carditis, with or without valvular disease, are at high risk for RHD recurrence should receive long-term antibiotics therapy as secondary prevention. Prophylactic antibiotic therapy should be continued even after valve surgery, irrespective of the valve location or type (including mechanical and biological valves replacement), since these patients remain at risk for recurrence of RHD for the involved valve or other valves.

• #2 Clinical Update – Secondary Prevention of ARF | Rheumatic Heart Disease Australia

  https://www.rhdaustralia.org.au/news/clinical-update-secondary-prevention-arf

  The most effective method is deep intramuscular, long-acting benzathine benzylpenicillin (BPG) injections every 21 to 28 days. […] Each injection needs to be given no later than day 28 after the last injection, because without the ongoing protection of the penicillin, there is a high risk of another Strep A infection and recurrent ARF. […] Recommendations for duration of secondary prophylaxis are made by balancing the risk of ARF recurrence and its consequences, against the difficulties associated with delivering and receiving regular injections. […] Ultimately, ceasing secondary prophylaxis is a decision between an individual and their medical specialist based on a detailed medical assessment and the expected risk of ARF recurrence. […] The recommended duration of secondary prophylaxis has changed from 10 years to five years for people with highly suspected and confirmed ARF, if there is no cardiac involvement or established RHD. […] If a person is aged over 35 years at the time of RHD diagnosis and there is no documented history of ARF, then secondary prophylaxis is not recommended.

• #2 Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012468

  Secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) involves continuous antimicrobial prophylaxis among affected individuals and is recognised as a cornerstone of public health programmes that address these conditions. […] Secondary prevention is the cornerstone of WHO-endorsed ARF and RHD control programmes and has been argued to be the most cost-effective strategy for reducing RHD mortality. […] Despite the widespread acceptance of secondary prevention, several critical scientific and practical questions remain unresolved. […] We need a better understanding of RHD epidemiology to guide programmes, policies and practice. […] We need better strategies to find and diagnose people affected by ARF and RHD. […] We urgently need better tools to manage ARF and slow the progression of RHD.

• #2 Sharing success – understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-016-0344-x

  Addressing low uptake of secondary prophylaxis for RF/RHD has been identified as a public health priority in Australia. […] The study findings provide insights that may facilitate enhancement of secondary prophylaxis delivery systems and thereby improve uptake of secondary prophylaxis for RF/RHD. […] The use of reminder/recall systems ensures that patients receive treatment reminders either prior to when treatments are due or, if the service is not provided in the relevant timeframe, when they become overdue. […] While health professionals clearly emphasise pain as a barrier to LAB uptake, it is not so clearly emphasised by patients and parents/carer givers. […] Understanding the gravity of RF/RHD means that some children, even from a young age, recognise the importance of receiving treatment.

• #2 Guidelines for the secondary prevention of rheumatic heart disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6372451/

  Rheumatic fever and rheumatic heart disease can be prevented with appropriate antibiotics administration to prevent the progression of valve damage. […] Generally, primary prevention of RF using the appropriate antibiotics to treat preceding Streptococcus pyogenes infection is considered the most effective method for preventing rheumatic heart disease. Moreover, RF can be prevented and controlled with regular antibiotics by inhibiting the risk for further S. pyogenes infections and causing progression of valve damage. Thus, heart valve surgery to repair or replace damaged heart valves can be prevented or delayed by using secondary prophylaxis antibiotics. […] All patients who have had rheumatic carditis, with or without valvular disease, are at high risk for RHD recurrence should receive long-term antibiotics therapy as secondary prevention. Prophylactic antibiotic therapy should be continued even after valve surgery, irrespective of the valve location or type (including mechanical and biological valves replacement), since these patients remain at risk for recurrence of RHD for the involved valve or other valves.

• #2 Research priorities for the secondary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012468

  New and existing technologies need to be better integrated into healthcare systems. […] Improving diagnosis of ARF in low-resource settings is a critical priority. […] Lack of ARF diagnosis represents an enormous opportunity loss to initiate secondary prevention, the only medical intervention known to improve outcomes. […] We do know that adherence can be optimised. […] The ongoing Active Case Detection and Decentralized Dynamic Registry to Improve the Uptake of Rheumatic Heart Disease Secondary Prevention (ADD-RHD) study is one example of an implementation science approach to secondary prevention. […] Critical investments in new knowledge, technologies and implementation research can modernise the playbook for RHD prevention and control and lead to better, more sustainable reductions in RHD than were achieved in the past, and hopefully at lower cost.

• #2 Rheumatic Heart Disease | What We Do | World Heart Federation

  https://world-heart-federation.org/what-we-do/rheumatic-heart-disease/

  Secondary prophylaxis: Once a patient has been identified as having had rheumatic fever, it is important to prevent additional streptococcal infections as this could cause a further episode of rheumatic fever and additional damage to the heart valves. The strategy to prevent additional streptococcal infection is to treat a patient with antibiotics over a long period of time. The antibiotic treatment that is most effective in preventing further infection is benzathine penicillin G, which is given by intramuscular injection every 3-4 weeks over many years. […] For countries where rheumatic heart disease is endemic, the main strategies for prevention, control and elimination include: Improving standards of living, Expanding access to appropriate care, Ensuring a consistent supply of quality-assured antibiotics for primary and secondary prevention, Planning, development and implementing feasible programmes for prevention and control of rheumatic heart disease, Adequate monitoring and surveillance.

• #3

  https://www.who.int/publications/i/item/9789240100077

  Rheumatic fever (RF) and Rheumatic heart disease (RHD) are a preventable public health problem in low- and middle-income countries and in marginalized communities in middle- and high-income countries. […] The WHO guideline on the prevention and diagnosis of rheumatic fever (RF) and rheumatic heart disease (RHD) provides evidence-informed recommendations for the prevention and management of RF and RHD. It encompasses three areas; 1) primary prevention of rheumatic fever and rheumatic heart disease, specifically the identification and treatment of suspected group A (beta-haemolytic) Streptococcus (GAS) pharyngitis and skin infections; 2) secondary prevention of recurrent rheumatic fever and of rheumatic heart disease, specifically use of long-term antibiotic prophylaxis, interventions to increase adherence to antibiotic prophylaxis, and screening for early rheumatic heart disease; and 3) management of rheumatic fever, specifically the treatment with anti-inflammatory drugs. […] The recommendations are intended for wide audience involved in the prevention and management of RF and RHD.

• #3

  https://www.health.nsw.gov.au/Infectious/controlguideline/Pages/rheumatic-heart-disease.aspx

  The priorities in the control and prevention of acute rheumatic fever (ARF) are: […] Secondary prevention with regular benzathine penicillin G after ARF diagnosis secondary prevention with regular benzathine penicillin G after ARF diagnosis. […] The current cornerstone of ARF/RHD preventive activities in Australia currently is secondary prophylaxis with an antimicrobial agent effective against GAS for those with diagnosed prior ARF/RHD. […] Secondary prophylaxis with intra muscular injections of benzathine penicillin G every 28 days significantly reduces ARF recurrence rates compared with placebo or oral penicillin and is the treatment of choice. This strategy forms the basis of the WHO’s ARF recommendations and Australia’s National Guidelines. […] Management of streptococcal pharyngitis: Treat with intramuscular BPG 900mg (450mg if 20kg) single dose or oral phenoxymethylpenicillin 500mg twice daily (250 mg twice if 34kg) for 10 days.

• #3 Secondary prevention | RHD Action

  https://rhdaction.org/treatment/secondary-prevention

  Secondary prophylaxis is the administration of antibiotics to people with a history of RF to prevent GAS infection, subsequent RF recurrence and to minimize progression to RHD. […] Secondary prophylaxis against RF was first recommended by the American Heart Association in the 1950s and remains the mainstay of disease altering therapy for RHD. […] Administration of the right antibiotics, at appropriate intervals, consistently over a number of years appears to prevent development of new GAS infections, and subsequent recurrences of RF. […] Preventing recurrences of RF slows, or perhaps even stops, the development of severe RHD. […] A number of guidelines have been developed to guide secondary prophylaxis regimes, providing advice about antibiotic choice, dose, frequency and duration of secondary prophylaxis.

• #3 Therapeutics for rheumatic fever and heart disease

  https://australianprescriber.tg.org.au/articles/therapeutics-for-rheumatic-fever-and-rheumatic-heart-disease.html

  The goals of acute rheumatic fever therapy are to relieve symptoms, mitigate cardiac valve damage and eradicate streptococcal infection. Preventing future recurrences requires long-term secondary antibiotic prophylaxis and ongoing prevention of Streptococcus pyogenes (group A streptococcus) infections. […] The recommended regimen for secondary prophylaxis comprises benzathine benzylpenicillin G intramuscular injections every four weeks. For patients with non-severe or immediate penicillin hypersensitivity, use erythromycin orally twice daily. […] Secondary antibiotic prophylaxis is the mainstay of treatment for acute rheumatic fever and rheumatic heart disease globally to prevent recurrences of rheumatic fever and thereby prevent cumulative valve damage with the development or progression of rheumatic heart disease.

• #3 Acute Rheumatic Fever Treatment & Management: Medical Care, Surgical Care, Consultations

  https://emedicine.medscape.com/article/333103-treatment

  Prevention of ARF has been successful in developed societies. The recommended approach can be divided into primary and secondary prevention. Primary prevention involves eradication of Streptococcus from the pharynx, which generally entails administering a single intramuscular injection of benzathine benzylpenicillin. […] For secondary prevention, the American Heart Association (AHA) Committee on Acute Rheumatic Fever recommends a regimen consisting of benzathine benzylpenicillin at 1.2 million units intramuscularly every 4 weeks. However, in high-risk situations, administration every 3 weeks is justified and advised. High-risk situations include patients with heart disease who are at risk of repetitive exposure. […] Oral prophylaxis, which is less reliable, consists of phenoxymethylpenicillin (penicillin V) or sulfadiazine. These can be used in compliant patients. If penicillin allergy is suspected, oral cephalosporins should be used.

• #3 Therapeutics for rheumatic fever and heart disease

  https://australianprescriber.tg.org.au/articles/therapeutics-for-rheumatic-fever-and-rheumatic-heart-disease.html

  The recommended regimen is intramuscular injections of benzathine benzylpenicillin G every four weeks for a minimum of five years (if there is no cardiac involvement) or 10 years (if there is cardiac involvement) after the last acute rheumatic fever episode or until 21 years of age, whichever is longer. […] Increasing adherence to benzathine benzylpenicillin G is associated with improved rheumatic fever outcomes. […] Regular oral penicillin is not as effective as benzathine benzylpenicillin G. […] 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 or 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).

• #3 Adherence to Secondary Prophylaxis for Acute Rheumatic Fever and Rheumatic Heart Disease: A Systematic Review

  https://www.eurekaselect.com/article/81077

  Optimal delivery of regular benzathine penicillin G (BPG) injections prescribed as secondary prophylaxis for acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is vital to preventing disease morbidity and cardiac sequelae in affected pediatric and young adult populations. […] However, poor uptake of secondary prophylaxis remains a significant challenge to ARF/RHD control programs. […] Insights into factors associated with lower and higher adherence to secondary prophylaxis may be utilized to facilitate improved delivery of secondary prophylaxis for ARF and RHD. Strategies may include ensuring an effective active recall system, providing holistic care, involving community health workers and delivering ARF/RHD health education.

• #3 Sharing success – understanding barriers and enablers to secondary prophylaxis delivery for rheumatic fever and rheumatic heart disease | BMC Cardiovascular Disorders | Full Text

  https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-016-0344-x

  Interview data also highlight fundamental differences in individual health professionals philosophical positions regarding who is responsible for patients treatment. […] The importance of local health service delivery reaching into the community is highlighted in this and previous studies. […] Education is a key component of improving chronic disease care and can be envisaged as falling under a number of components of the CCM: community resources and policy, informed empowered patients, and prepared proactive health team. […] Health professionals, who establish trusting relationships with patients, particularly children, feel that they are able to influence prophylaxis uptake. […] Delivery of secondary antibiotic prophylaxis for RF/RHD remains a priority for reducing the impact of this preventable cause of heart disease both in Australia and globally.

• #3 Rheumatic Heart Disease | What We Do | World Heart Federation

  https://world-heart-federation.org/what-we-do/rheumatic-heart-disease/

  Rheumatic heart disease is a preventable yet serious public health problem in low- and middle-income countries and in marginalized communities in high-income countries, including indigenous populations. […] Effective early intervention can prevent premature mortality from rheumatic heart disease. […] There are three levels of prevention for rheumatic heart disease: reducing the risk factors for rheumatic fever (primordial prevention); primary prevention of rheumatic fever and rheumatic heart disease; and secondary prevention (prophylaxis) of rheumatic fever and rheumatic heart disease. […] Primordial prevention aims to avoid episodes of strep throat by tackling poverty, improving living and housing standards, and increasing access to health care. […] Primary prevention of rheumatic fever can be achieved through the effective treatment of strep throat with appropriate antibiotics (penicillin).

• #3 Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012356

  Primary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) encompasses the timely diagnosis and adequate treatment of the superficial group A Streptococcus (GAS) infections pharyngitis and impetigo. […] However, sufficient evidence indicates that the uptake and delivery of primary prevention approaches in RHD-endemic regions are significantly suboptimal. […] The opportunities identified by the Primary Prevention Working Group encompass epidemiological, laboratory, clinical, implementation and dissemination research domains and are anchored on five pillars including: (A) to gain a better understanding of superficial GAS infection epidemiology to guide programmes and policies; (B) to improve diagnosis of superficial GAS infections in RHD endemic settings; (C) to develop scalable and sustainable models for delivery of primary prevention; (D) to understand potential downstream effects of the scale-up of primary prevention and (E) to develop and conduct economic evaluations of primary prevention strategies in RHD endemic settings.

• #4 How Will My Rheumatic Fever Be Managed? | KidsHealth New Zealand’s Trusted Voice On Children’s Health

  https://www.kidshealth.org.nz/how-will-my-rheumatic-fever-be-managed

  To stop the strep germ from getting into the body and to prevent rheumatic fever from happening again, you will need to have an injection of benzathine penicillin, also known as bicillin, every 21 to 28 days. You may hear healthcare professionals call this secondary prophylaxis. […] If you are late, it increases your chance of rheumatic fever happening again. […] Most people need bicillin injections for 10 years after the last rheumatic fever episode or until they are 21 years old (whichever is the longer period). Your health worker, nurse or doctor can tell you more about the treatment. Your rheumatic fever specialist will tell you when it is safe to stop having bicillin injections.

• #4

  https://journals.lww.com/jfmpc/fulltext/2020/09030/compliance_to_the_secondary_prophylaxis_and.25.aspx

  A good adherence to the regular secondary prophylaxis would prevent recurrences of ARF in any patient who had suffered from ARF previously. […] Poor adherence to secondary prophylaxis for rheumatic fever has been observed due to poor knowledge. […] General public awareness activities are vital for a successful RHD control program. […] Awareness regarding this disease among common people and regular secondary prophylaxis are vital for the prevention and control of this disease. […] A large number of patients had poor knowledge about this disease; hence, in the regions with significant disease burden, there is a need of spreading awareness regarding this disease among common people so that more people seek medical attention for sore throat and they adhere to the regular secondary prophylaxis if diagnosed with ARF/RHD.

• #4 Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012356

  There are significant opportunities to improve the uptake and delivery of primary prevention through targeted campaigns for treatment of sore throats and skin sores in RHD-endemic regions. […] Implementation research to optimise primary prevention of ARF/RHD is a key focus and spans epidemiological, laboratory, clinical, translation and dissemination research specialties. […] Achieving improvements in primary prevention will require multisectoral stakeholder collaboration, emphasising the need to engage local communities, government agencies, non-governmental organisations and local, regional and international advocacy groups. […] The PPWG proposes a list of key opportunities for improving primary prevention uptake and delivery. […] The PPWG identified the following research priorities for development of scalable and sustainable models for delivery of primary prevention: Develop, test and compare novel approaches to integrate primary prevention into existing physical settings and organisational structures (ie, school-based, community-based, healthcare system-based using new diagnostics).

• #5 Research opportunities for the primary prevention and management of acute rheumatic fever and rheumatic heart disease: a National Heart, Lung, and Blood Institute workshop report | BMJ Global Health

  https://gh.bmj.com/content/8/Suppl_9/e012356

  Use rigorous implementation and dissemination methodology to study the impact of integrated primary prevention programmes including community sensitisation, healthcare worker education and implementation of tools to improve local diagnostic capacity. […] The ability to prevent ARF cases by treating superficial GAS infections dictate the need to diagnose and treat these infections at an individual level; therefore, improving and innovating strategies for GAS diagnosis and treatment cannot be neglected. […] Scalable and sustainable models for delivery of primary prevention are needed, as well as the conduct of economic evaluation of these primary prevention strategies. […] Community and government engagement especially in the implementation and dissemination research of various primary prevention strategies cannot be overstated.

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