Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease

©2007 World Heart Federation … Updated October 2008

Diagnosis and Management of Acute Rheumatic Fever

and

Rheumatic Heart Disease


Secondary Prophylaxisto prevent recurrent ARF


This presentation is intended to support the Curriculum for training health workers and others involved in the diagnosis and management of acute rheumatic fever and rheumatic heart disease.

It has been made possible thanks to the support of the Vodafone Group Foundation and the International Solidarity, State of Geneva, and the ongoing support of Menzies School of Health Research, Caritas Australia, Fiji Water Foundation, Cure Kids and Accor Hospitality.


Secondary Prophylaxis

Secondary prophylaxis is the terms used to describe regular delivery of antibiotics to

prevent recurrence of GAS infection and subsequent development of ARF.

Secondary prophylaxis is recommended for people who have had ARF, or who have

RHD to

– Prevent further Group A Streptococcal infections

– Prevent recurrence ARF

– Prevent the development or worsening of RHD

– Reduce the severity of RHD

– Help reduce the risk of death from severe RHD.


Standard Treatment

Benzathine penicillin G

1,200,000 units for ALL people ≥30kg

600,000 units for children <30kg

Every 3 or 4 weeks (by intramuscular injection)

Penicillin V

Given if needles cannot be given due to excessive bleeding

250mg twice daily (by mouth)

Erythromycin

Given if Penicillin allergy has been confirmed by a Medical Officer

250mg twice daily (by mouth)


Considerations

When should secondary prophylaxis be considered?– ARF confirmed by the Revised Jones Criteria

– RHD confirmed on echocardiogram

– ARF or RHD not confirmed by the Revised Jones Criteria, but considered highly ‘probable’

Precautions– Do not give Benzathine Penicillin G or Penicillin V if there is a documented Penicillin allergydocumented Penicillin allergy

– Drug reactions are rare

Continue secondary prophylaxis during pregnancy

Continue secondary prophylaxis during anticoagulation (e.g. with Warfarin)


– Age at first diagnosis of ARF (or RHD)

– Severity of disease

– If carditis was present with first ARF

Disease Classification Duration of secondary prophylaxis

ARF (no carditis)

Minimum of 5 years after last ARF, or Until age 18 years (whichever is longer)

Mild-moderate RHD(or healed carditis)

Minimum of 10 years after last ARF, or Until age 25 years (whichever is longer)

Severe RHD and after Surgery

Continue for life

– Time (years) since last ARF illness

– Ongoing risk factors (e.g. level of poverty)

– If medication is received regularly

Length of time for secondary prophylaxis depends on a number of factors including

Guidelines for Secondary Prophylaxis

** Secondary prophylaxis guidelines may vary **

World Health Organisation guidelines for secondary prophylaxis duration:


Secondary Prophylaxis should only be ceased following:

No ARF signs/symptoms for at least 5 years,

and

Medical Specialist review (Paediatrician / Physician / Cardiologist)

and

Echocardiogram to establish presence & severity of RHD (if available)

Ceasing Secondary Prophylaxis


Assessment and Preparation

– Confirm person’s identity

– Review known drug allergies

– Discuss and record any recent ARF or RHD symptoms (refer to medical officer if required)

– Obtain consent for injection

Benzathine Penicillin injection delivery


Check medication name, dose and expiry date

Prepare medication according to the product information

– Administer 1,200,000 units for all persons ≥ 30kg

– Administer 600,000 units for small children <30kg

Administer with a size 23-gauge needle

Dispose of used needles and syringes in a puncture-proof container.

Use a new needle and syringe for each injection

Administer medication immediately after preparation

Benzathine Penicillin injection delivery


Documentation

Record in the Benzathine penicillin injection book and/or medical notes

– Dose and batch number

– Date given and date next due

– Signature (of person giving injection)

Record next date due on a reminder card (if applicable)


1. Record the number of injections PRESCRIBED for the full year

– 13 injections should be given each year if prescribed every 4 weeks

– 17 injections should be given each year if prescribed every 3 weeks

2. Count the number of injections GIVEN in the full year

3. Calculate the number of injections GIVEN (10) divided by the number

PRESCRIBED (13) and multiply by 100.

EXAMPLE: If 13 injections are PRESCRIBED, and 10 were GIVEN:

(10 ÷ 13) x 100 = 77% RECEIVED

In this example, 77% of injections were RECEIVED for the individual for the year.

Calculating Injection Delivery


Receiving less than 80% of injections places an individual at higher risk of recurrent ARF– Follow-up may be required

If injections were PRESCRIBED for the full year but none were GIVEN, record 0%.

Receiving less than 50% of injections places an individual at extreme risk of recurrent ARF

and progression of RHD

– Immediate intervention is required for this individual.Immediate intervention is required for this individual.

Notes on Injection Delivery


Factors affecting Injection Delivery

Relationship between the person with ARF/RHD & the health system

Education of the person, family & health workers

Person / family refusing treatment

Person forgetting treatment

Difficulty traveling to health facility

Pain and fear of injections

Health staff workloads and priorities

Alternative therapy use / distrust of health service


Strategies to improve Injection DeliveryAppoint a dedicated staff member at each clinic to oversee secondary prophylaxis

coordination

Identify people who need secondary prophylaxis

Identify local health facility for each person

Develop systems for follow-up

Provide ongoing education for people who require injections and their families

Communicate with local RHD programme and other health service providers

Reduce injection pain

Discuss alternative therapy issues


Symptoms

– Skin rash

– Itchy eyes

Treatment

Antihistamine (oral or injection)

Penicillin Allergy


Symptoms

– Wheezing

– Hives

– Itching

– Swelling of the face and lips

– Difficulty breathing

– Vomiting

– Falling Blood pressure

– Loss of consciousness

– Cardiac arrest

Anaphylaxis

Treatment

Adrenaline (subcutaneous injection)


Summary

Antibiotics need to be present in the body at all times to help prevent GAS infections and

prevent recurrent ARF

Benzathine penicillin injections should be given unless there are contraindications to

injections or documented penicillin allergy

Medical Specialist review is required before ceasing secondary prophylaxis

Strategies to improve secondary prophylaxis delivery:

– Good relationships between community and health staff

– Education for the community and health staff

– Systems for follow-up

– Communication between health services

– Reduce injection pain

Document Benzathine Penicillin injections and monitor injection delivery

Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease

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