Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis

TLDR

Primary prevention of rheumatic fever relies on early detection and adequate antibiotic treatment of group A β‑hemolytic streptococcal tonsillopharyngitis, with penicillin as the preferred therapy and alternatives for penicillin‑allergic patients, while secondary prophylaxis for those with prior rheumatic fever is tailored to attack history, exposure risk, and cardiac status. This report updates the 1995 American Heart Association statement on rheumatic fever, endocarditis, and Kawasaki disease. The update provides new recommendations for diagnosing and treating GAS pharyngitis and for secondary prevention of rheumatic fever, and grades the strength of recommendations and evidence levels.

Abstract

Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A beta-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. 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 recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS 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 a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them.