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Treatment of Acute Streptococcal Pharyngitis and Prevention of Rheumatic Fever: A Statement for Health Professionals
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1995
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Primary prevention of rheumatic fever relies on prompt diagnosis of group A β‑hemolytic streptococcal pharyngitis—best detected by throat culture—and treatment with penicillin, with macrolides, cephalosporins, or other β‑lactams as alternatives for penicillin‑allergic patients, while individuals with prior rheumatic fever require continuous secondary prophylaxis. This report updates the 1988 committee statement, incorporating newer therapeutic options and more specific guidance on the duration of secondary prophylaxis. Secondary prophylaxis duration is tailored to attack history, time since last attack, exposure risk, age, and cardiac involvement, with penicillin as first‑line therapy and sulfadiazine or erythromycin as alternatives for penicillin‑allergic patients.
Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A β-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by a throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) remains the treatment of choice, because it is cost effective, has a narrow spectrum of activity, has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. Various macrolides, oral cephalosporins, and other β-lactam agents are acceptable alternatives, particularly in penicillin-allergic individuals. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The duration of prophylaxis depends on the number of previous attacks, the time lapsed since the last attack, the risk of exposure to streptococcal infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or erythromycin are acceptable alternatives in penicillin-allergic individuals. This report is an update of a 1988 statement by this committee. It expands on the previous statement, includes more recent therapeutic modalities, and makes more specific recommendations for the duration of secondary prophylaxis.