Prevention and treatment of group A streptococcal infection can prevent rheumatic fever. There are two forms of prevention for acute rheumatic fever, primary prophylaxis and secondary prophylaxis.

Primary prophylaxis refers to antibiotic treatment of the streptococcal upper respiratory tract infection to prevent an initial attack of rheumatic fever. Appropriate diagnosis and adequate antibiotic therapy with eradication of group A streptococci from the upper respiratory tract reduce the risk of developing rheumatic fever to near zero. Antibiotic therapy initiated up to approximately 1 wk after onset of the streptococcal sore throat can prevent rheumatic fever. See Chapter 175 for treatment of group A streptococcal infections. However, antibiotic therapy must be adequate. Ten full days of oral therapy are essential if the oral method is used.

Secondary prophylaxis refers to the prevention of colonization or infection of the upper respiratory tract with group A b{beta}-hemolytic streptococci in people who have already had a previous attack of acute rheumatic fever. Patients who receive antibiotics continuously and do not have group A streptococcal infections do not have recurrences of rheumatic fever. The recommended methods of secondary prevention include regular monthly (every 3{endash}–4 wk) injections of intramuscular benzathine penicillin G, daily administration of oral penicillin, daily administration of oral sulfadiazine, or daily oral administration of erythromycin (for individuals who cannot take any of the previously recommended antibiotics). Although sulfadiazine or other sulfa drugs should never be used for the treatment of group A streptococcal infections (because a high percentage of organisms are resistant to these antimicrobial agents), sulfadiazine is effective in preventing colonization of the upper respiratory tract and is an acceptable form of oral secondary prophylaxis. Regular injections of intramuscular benzathine penicillin G are preferable to oral secondary prophylaxis because of better compliance. Individuals at high risk for rheumatic recurrence should be given 1,200,000 units intramuscularly every 3 wk. Penicillin levels during the 4th wk following injection may be lower than the MIC for group A b{beta}-hemolytic streptococci. However, in most instances in the United States 4-wk intervals for injections are sufficient because the risk of recurrence of rheumatic fever is small.

 

The necessary duration of secondary prophylaxis in individuals with a documented history of rheumatic fever or with rheumatic heart disease is controversial. Recurrences of acute rheumatic fever occur less frequently 5 yr or more after the most recent attack, and for this reason, some clinicians think that patients may not need secondary prophylaxis more than 5 yr after the most recent attack or when they reach their 18th birthday, whichever comes first. Others recommend that, in patients who have significant rheumatic heart disease or who have a significant risk of contracting group A streptococcal upper respiratory tract infection (e.g., medical professionals, school teachers, those living in crowded conditions), the duration of secondary prophylaxis should be longer. Some recommend that treatment be continued for life in patients with rheumatic valvular heart disease. Recommendations for each patient must be individualized, depending on the patient's condition and the environment in which he or she lives and works.

 

No streptococcal vaccine is available. Physicians and public health authorities must still depend on the accurate and timely diagnosis and therapy of group A streptococcal upper respiratory tract infections and prevention of recurrent infections in known rheumatics to prevent the crippling effects of rheumatic fever and rheumatic heart disease.