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Secondary prevention of further episodes of ARF is a priority. Secondary prophylaxis with regular benzathine penicil in G (BPG) is the only RHD control strategy shown to be effective and cost-effective at both community and population levels. This quick reference guide is derived from the Australian guideline for prevention, diagnosis and management of acute rheumatic fever and Although ARF is relatively rare in industrialised rheumatic heart disease (2nd edn).
countries, in Australia it is a significant illness among Aboriginal people and Torres Strait Islanders, particularly across central and northern Australia. Pacific Islanders, and migrants from countries with a high prevalence of RHD, are also known to be at high risk.
Acute rheumatic fever (ARF) is an il ness caused by a reaction to a bacterial infection with group Secondary prevention
A streptococcus (GAS). It causes an acute, generalised inflammatory response and an il ness Secondary prevention of further episodes of that targets specific parts of the body, including ARF is a priority. Secondary prophylaxis with regular benzathine penicillin G (BPG) is the only the heart, joints, brain and skin. Individuals with ARF are often unwel , have significant joint pain RHD control strategy shown to be effective and and require hospitalisation. Despite the dramatic cost-effective at both community and population nature of the acute episode, ARF typical y leaves no lasting damage to the brain, joints or skin, but can cause persisting heart damage, termed prophylaxis is determined by age, time since ‘rheumatic heart disease’ (RHD). People who have the last episode of ARF and potential harm from had ARF previously are much more likely than the recurrent ARF, but is likely to be 10 years or more. wider community to have subsequent episodes. Recurrences of ARF may cause further cardiac valve damage. Hence, RHD steadily worsens in strategy for controlling RHD, and is also simple, cheap and cost-effective, it must be adequately people who have multiple episodes of ARF.
implemented. Persistent high rates of recurrent ARF in high-risk populations highlight the continued barriers to secondary prevention. 4. Secondary prevention of acute rheumatic fever The effectiveness of secondary prophylaxis is impaired by factors that contribute to poor adherence to antibiotic regimens and increased • strategies aimed at improving the delivery of incidence rates of ARF. These factors relate to overcrowded housing, poor access to health services, limited educational opportunities and poor environmental conditions. Communities • coordination of available health services with the highest rates of ARF and RHD are often • advocacy for necessary and appropriate the least equipped to deal with the problem. Antibiotic regimens for secondary prophylaxis
Antibiotic
Frequency
First line
BPG
Second line (If im route is not possible or refused, adherence should be carefully monitored)
Phenoxymethylpenicillin 250 mg
(Penicillin V)
Following documented penicillin allergy
Erythromycin
* Three-weekly BPG may be considered for patients with moderate or severe carditis or a history of valve surgery, who demonstrate good adherence to less frequent injections, and for those who have confirmed breakthrough ARF, despite full adherence to 4-weekly BPG.
BPG, benzathine penicillin G; im, intramuscular.
Measures that may reduce the pain of BPG injections
• Deliver injection very slowly (preferably over • Warm syringe to room temperature before using • Distract patient during injection (e.g. with • Allow alcohol from swab to dry before inserting • (The addition of 0.5–1.0 mL of 1% lignocaine • Apply pressure with thumb for 10 sec before is used elsewhere, but is not recommended with preloaded syringes currently available in Australia) The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd Edition) Factors that affect the duration of secondary prophylaxis
Implication
ARF recurrence is less common between 25–40 years of age, Presence and severity of RHD
ARF recurrence could be life-threatening in people with moderate or severe RHD, or in those with a history of valve surgery Presence of carditis during initial Increases the likelihood of further cardiac damage, should a
episode
Time elapsed since last episode
ARF recurrences are less common >5 years since last episode of ARF
Socioeconomic circumstances
ARF recurrences are more common in lower socioeconomic groups (particularly related to overcrowded housing) Background risk of GAS infection ARF recurrences are more common in higher-incidence
and ARF within the community
Adherence to treatment
Optimised adherence for a few years after the initial episode may provide greater protection from recurrences than offered by poor adherence for many years Assessment at time of cessation
Evidence of moderate or greater RHD may warrant prolonged of secondary prophylaxis
rheumatic heart disease 5. Management of 4. Secondary prevention of acute rheumatic fever Duration of secondary prophylaxis
Category
Definition of category
Duration
All persons with ARF or RHD†
Minimum 10 years after most recent episode of ARF or until age 21 years (whichever is longer).
Status after initial period elapsed:
No RHD
No pathological mitral or aortic regurgitation, Discontinue at that time#but may have minor morphological changes to mitral or aortic valves on echocardiography Mild mitral or aortic regurgitation clinical y and Discontinue at that timeon echocardiography, with no clinical evidence of heart failure, and no evidence of cardiac chamber enlargement on echocardiography Moderate RHD
• Any valve lesion of moderate severity clinically (e.g. mild–moderate cardiomegaly and/or mild–moderate heart failure) or on echocardiography • Mild mitral regurgitation, together with mild aortic regurgitation clinically or on echocardiography • Mild or moderate mitral or aortic stenosis • Any pulmonary or tricuspid valve lesion co-existing with a left-sided valve lesion Severe RHD
• Any severe valve lesion clinically (e.g. moderate to severe cardiomegaly or heart • Any impending or previous cardiac valve † Patients >25 years of age who are diagnosed with RHD, without any documented history of prior ARF, should receive prophylaxis until the age of 35 years. At this time, they should be reassessed to determine whether prophylaxis should be continued. #Decisions to cease secondary prophylaxis should be based on clinical and echocardiographic assessment. *Risk of recurrence is extremely low in people aged >40 years. In some cases, for example, when the patient decides that they want to reduce even a minimal risk of recurrence, prophylaxis may be continued beyond the age of 40 years, or even for life.
The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd Edition) Improving adherence to secondary
• having local staff members dedicated to prophylaxis
A variety of factors, mainly sociological, combine to limit the efficacy of secondary prophylaxis. • supporting and utilising the expertise, A major reason for poor adherence in remote Aboriginal and Torres Strait Islander communities language skills of Aboriginal health workers is the availability and acceptability of health services, rather than personal factors, such as • improving staff awareness of the diagnosis and injection refusal, pain of injections or a lack of knowledge or understanding of ARF and RHD. • taking measures to minimise staff turnover Adherence is improved when patients feel a • implementing measures to reduce the pain of sense of personalised care and ‘belonging’ to the clinic, and when recall systems extend beyond the boundaries of the community.
Procedures requiring endocarditis
prophylaxis for patients with RHD
prophylaxis (including the use of registers) are outlined in the information sheet RHD control complication of RHD including those with prosthetic valves. People with prosthetic valves Strategies to promote continuing adherence or established RHD, should receive antibiotic prophylaxis prior to procedures expected to produce bacteraemia (see below). • routine review and care planning (see below) Dental, oral and respiratory tract procedures
rheumatic heart disease 5. Management of Intraligamentary local anaesthetic injections Initial placement of orthodontic appliances Surgical repair or fixation of a fractured jaw 4. Secondary prevention of acute rheumatic fever Antibiotic
For patients on long-term penicillin therapy, hypersensitive to penicillin or who have taken penicillin
or a related beta-lactam antibiotic more than once in the last month:
Clindamycin
(Child: 15 mg/kg, up to 600 mg) 600 mg orally as 1 dose 1 hour before procedure If unable to take orally
Clindamycin
(Child: 15 mg/kg, up to 600 mg) 600 mg iv, over at least 20 mins just before procedure Or vancomycin
(Child less than 12 years: 30 mg/kg up to 1.5 g) 1.5 g iv by slow infusion, over at least 1 hour just prior to procedure Or lincomycin
(Child: 15 mg/kg, up to 600 mg) 600 mg iv, over 1 hour before procedure Or teicoplanin
(Child: 10 mg/kg, up to 400 mg) 400 mg iv, just before the procedure or im 30 mins before procedure For patients not on long-term penicillin therapy, not hypersensitive to penicillin and who have not
taken penicillin or a related beta-lactam antibiotic more than once in the last month:
Amoxycillin
(Child: 50 mg/kg up to 2 g) 2 g orally as 1 dose 1 hour prior to the procedure Or amoxycillin/
(Child: 50 mg/kg up to 2 g) 2 g iv just prior to procedure or im 30 min ampicillin
Genitourinary and gastrointestinal procedures
• Surgery of the intestinal mucosa or biliary
• Vaginal delivery in the presence of infection, or prolonged labour or prolonged rupture of • Endoscopic retrograde cholangiography • Surgical procedures of the genitourinary tract in the presence of infection (e.g. urethral catheterisation, uterine dilatation and curettage, abortion, sterilisation and placement or removal of intrauterine contraceptive devices) Antibiotic
Vancomycin
(Child <12 years: 30 mg/kg, up to 1.5 g) 1.5g iv by slow infusion, over at least 1 hour just prior to procedure Or teicoplanin
(Child: 10 mg/kg up to 400 mg) 400 mg iv just prior to procedure The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd Edition) Recommended routine review and management plan for ARF and RHD
Classification
Criteria*
Review and management plan
Frequency†
Priority 1
(severe)¥
Priority 2
(moderate)
Within 3 months of diagnosis, then 6 monthly Refer to Therapeutic Guidelines: Antibiotics 2010 Priority 3
4. Secondary prevention of acute rheumatic fever Classification
Criteria*
Review and management plan
Frequency†
Refer to Therapeutic Guidelines: Antibiotics 2010 Priority 4
(inactive)
whom secondary prophylaxis has been ceased Additional
considerations surgery
have not presented within 3 days of due injection to 2–3 weeks, or arrangements made with other service providers in advance * Serial echocardiographic assessments are required in the long-term management of RHD as an essential tool in determining the progress of cardiac damage and the optimal timing of surgery. Therefore, risk stratification should be based on clinical and echocardiographic findings (Grade D). †Review frequency should be determined according to individual needs and local capacity. Most critically, the frequency of review should become more frequent in the event of symptom onset, symptomatic deterioration or a change in clinical findings. ¥Any patient with severe valvular disease or moderate to severe valvular disease with symptoms should be referred for cardiological and surgical assessment as soon as possible. ‡In patients with no evidence of valvular disease on echocardiography, who have no documented ARF recurrences, good adherence to secondary prophylaxis and no cardiac murmurs on examination at follow up appointments, echocardiography may not be needed as frequently.
BPG, benzathine penicillin G; ECG, electrocardiogram; INR, international normalised ratio.
The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd Edition)

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