Medication Summary
Treatment and prevention of group A streptococci pharyngitis outlined here are based on the current recommendations of the American Heart Association Practice Guidelines on Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis. [24] Medical therapy is directed toward elimination of GAS pharyngitis (if still present), suppression of inflammation from the autoimmune response, and supportive treatment of congestive heart failure (CHF). Attempts are being made to produce vaccines against GAS infection, but the vaccines will not be available for years.
Antibiotics for endocarditis prophylaxis are administered to patients with certain cardiac conditions, such as carditis caused by rheumatic fever, before procedures that may cause bacteremia are performed. For more information, see Antibiotic Prophylactic Regimens for Endocarditis.
Antibiotics
Class Summary
The roles for antibiotics are to (1) initially treat GABHS pharyngitis, (2) prevent recurrent streptococcal pharyngitis, rheumatic fever (RF), and rheumatic heart disease (RHD), and (3) provide prophylaxis against bacterial endocarditis.
Penicillin VK (Beepen-VK, Pen.Vee K, V-Cillin K, Veetids)
For primary (decrease likelihood of rheumatic fever by treatment of GABHS pharyngitis) as well as secondary (prevention of recurrent rheumatic fever/carditis) prophylaxis of rheumatic fever. Although amoxicillin may be used instead, there is no microbiologic advantage. Do not use tetracyclines to treat GABHS pharyngitis. For recurrent GABHS pharyngitis, a second 10-d course of the same antibiotic may be repeated. Alternate drugs (penicillin allergic patients) include azithromycin, clarithromycin or clindamycin.
Penicillin G benzathine/penicillin G procaine (Bicillin C-R, Bicillin C-R 900/300)
For primary (decrease likelihood of rheumatic fever by treatment of GABHS pharyngitis) as well as secondary (prevention of recurrent rheumatic fever/carditis) prophylaxis of rheumatic fever. Used when PO administration of penicillin is not feasible or dependable. IM therapy with penicillin is painful, but discomfort may be minimized if penicillin G is brought to room temperature before injection or combination of benzathine penicillin G and procaine penicillin G is used. Initial course of antibiotics administered to eradicate streptococcal infection also serves as first course of prophylaxis. An injection of benzathine penicillin G IM q4wk is recommended regimen for secondary prevention for most United States patients. Administer same dosage q3wk in areas where RF is endemic, in patients with residual carditis, and in high-risk patients.
Amoxicillin (Amoxil, Biomox, Trimox)
May be used instead of Penicillin VK for primary prevention of rheumatic fever
Clarithromycin (Biaxin)
Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.
Azithromycin (Zithromax)
Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)
Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.
Sulfadiazine
May be used for secondary prevention of rheumatic fever
Anti-inflammatory agents
Class Summary
Manifestations of acute rheumatic fever (including carditis) typically respond rapidly to therapy with anti-inflammatory agents. Aspirin, in anti-inflammatory doses, is DOC. Prednisone is added when evidence of worsening carditis and heart failure is noted.
Aspirin (Anacin, Ascriptin, Bayer Aspirin)
Begin administration immediately after diagnosis of RF. Initiation of therapy may mask manifestations of disease.
Prednisone (Deltasone, Orasone)
If moderate-to-severe carditis is present as indicated by cardiomegaly, CHF, or third-degree heart block, use 2 mg/kg/d PO prednisone in addition to or in lieu of salicylate therapy. Continue prednisone for 2-4 wk depending on severity of carditis and taper during last week of therapy. Discontinuing prednisone therapy after 2 wk while adding or maintaining salicylates for additional 2-4 wk may minimize adverse effects.
Therapy for congestive heart failure
Class Summary
Heart failure in RHD probably is related in part to severe insufficiency of the mitral and aortic valves and in part to pancarditis. Therapy traditionally has consisted of an inotropic agent (digitalis) in combination with diuretics (furosemide, spironolactone) and afterload reduction (captopril).
Digoxin (Lanoxin, Lanoxicaps)
Inotropic agent widely used in past. Its efficacy in CHF is under review. Potential for toxicity is present. Therapeutic levels and clinical effects are observed more quickly if loading doses of digitalis are administered before routine maintenance doses. Acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure. Therapeutic digoxin levels are present at trough levels of 1.5-2 ng/mL.
Captopril (Capoten)
Systemic afterload reduction may be helpful in improving cardiac output, particularly in setting of mitral and aortic valve insufficiency. Some patients have unusually large hypotensive response. Use small starting dose, particularly with hypovolemia.
Furosemide (Lasix)
Diuretics frequently are used in conjunction with inotropic agents for patients with CHF. When used aggressively, may result in hypokalemia and hypovolemia. Risk of hearing loss in premature infants.
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule.
Spironolactone (Aldactone)
Used in conjunction with furosemide as potassium-sparing diuretic.
Competes with aldosterone for receptor sites in distal renal tubules, increasing water excretion while retaining potassium and hydrogen ions.
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Clinical manifestations and time course of acute rheumatic fever.
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Chest radiograph showing cardiomegaly due to carditis of acute rheumatic fever.
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Erythema marginatum, the characteristic rash of acute rheumatic fever.
