Choice of antibiotic agent for treatment and prophylaxis of acute rheumatic fever

Scenario	Antibiotic choice(s)
Preferred treatment in endemic areas where IM penicillin is available at low cost	IM penicillin G benzathine given every 28 days
Alternative treatment in nonendemic areas where IM penicillin is unavailable or prohibitively expensive	Oral penicillin V
Confirmed penicillin allergy*	Preferred – Oral azithromycin Alternative – Oral sulfadiazine
Severe symptomatic RHD^¶	Preferred – Oral penicillin V Alternatives – Oral azithromycin or oral sulfadiazine
Bleeding problems following IM injection that cannot be addressed	Preferred – Oral penicillin V Alternatives – Oral azithromycin or oral sulfadiazine
Other barriers to using the preferred treatment that cannot be resolved^Δ	Oral penicillin V
Patients at low risk of recurrence^◊	Oral penicillin V
Breakthrough infection while on prophylaxis	For treatment of acute infection – Oral clindamycin For ongoing prophylaxis – IM penicillin G benzathine given every 21 days

This table summarizes our suggested approach to selecting an antibiotic agent for treatment and prophylaxis of ARF. Patients who have had ARF who subsequently develop GAS infections are at high risk for a recurrent ARF attack, which increases the risk of developing more severe RHD. GAS infection need not be symptomatic to trigger a recurrent attack of ARF. Thus, the most effective method to limit progression of RHD is prevention of recurrent GAS infections. IM penicillin G benzathine is the preferred agent for treatment and prophylaxis of ARF in most cases. However, in select circumstances, an alternative agent may be appropriate, as summarized above. For additional details, refer to UpToDate topics on ARF and RHD.

IM: intramuscular; RHD: rheumatic heart disease; ARF: acute rheumatic fever; GAS: Group A Streptococcus; NYHA: New York Heart Association; EF: ejection fraction.

* Penicillin allergy should be verified by history and confirmed with testing by an allergy specialist if available before choosing an alternative to penicillin G benzathine.

¶ This includes patients with severe symptomatic valvular disease, NYHA class III or IV heart failure symptoms, and/or ventricular dysfunction (ie, EF <50%). Oral therapy is preferred for these patients because they can experience vasovagal reactions with IM injections, and this may increase the risk of sudden death.

Δ Additional barriers include patient concerns (eg, extreme needle phobia) that persist despite appropriate counseling and reassurance.

◊ Patients at low risk of recurrence include those who have reached young adulthood and have remained free of ARF attacks for several years.

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