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How to Treat Rheumatic Heart Disease?


Things to note:
  • Acute stage: bed rest and supportive care.
  • Patient education.
  • Intensive health education for prevention of sore throats.

Medical Treatment:
Acute rheumatic fever
For eradication of streptococci in throat:
  • Benzathine benzylpenicillin (depot formulation), IM, 1.2 million units as a single dose.
OR
  • Phenoxymethylpenicillin, oral, 500 mg 12 hourly for 10 days.
Penicillin allergy:
Macrolide, e.g:
  • Erythromycin, oral, 250 mg 6 hourly for 10 days.
Prevention of recurrent rheumatic fever
  • All patients with confirmed rheumatic fever and no rheumatic valvular disease - treat until 21 years of age.
  • All patients with confirmed rheumatic fever and rheumatic valvular disease - treat until 35 years of age.
    • Benzathine benzylpenicillin (depot formulation), IM, 1.2 million units every 3-4 weeks.
OR
  • Phenoxymethylpenicillin, oral, 250 mg 12 hourly.
Penicillin allergy:
  • Erythromycin, oral, 250 mg 12 hourly
Prophylaxis for infective endocarditis
  • Treat accompanying complications, e.g. cardiac failure.
Antibiotic therapy
  • Before starting antibiotics, it is essential to do at least three and no more than six blood cultures taken by separate venipunctures.
  • In patients with subacute presentation and no haemodynamic compromise, wait for the results before starting antibiotics.
  • Empiric treatment is indicated in patients with a rapidly fulminant course or with the severe disease only.
  • Aminoglycoside therapy should be monitored with trough levels for safety.
  • The therapy duration given is the minimum and can be extended based on the response (clinical and laboratory).
  • In penicillin-allergic patients vancomycin is the antibiotic of choice.
Directed therapy for prosthetic valve endocarditis
  • The therapy duration is usually at least 6 weeks.
  • Seek expert opinion on antibiotic choice.
Endocarditis prophylaxis
Cardiac conditions
Patients with the following cardiac conditions are at risk of developing infective endocarditis:
  • Acquired valvular heart disease with stenosis or regurgitation.
  • Prosthetic heart valves.
  • Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus.
  • Previous endocarditis.
Procedures requiring prophylaxis
  • Antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of either the gingival tissue or the peri-apical region of the teeth.
  • Antibiotic prophylaxis is not recommended for patients who undergo a gastro-intestinal or genito-urinary procedure.
Prophylaxis
  • Maintain good dental health.
  • This is the most important aspect of prophylaxis.
  • Refer all patients to a dental clinic/dental therapist for assessment and ongoing dental care.
    • Amoxicillin, oral, 2 g one hour before the procedure.
Penicillin allergy:
  • Clindamycin, oral, 600 mg one hour before the procedure.
If patient cannot take oral:
  • Ampicillin, IV/IM, 2 g one hour before the procedure.
Penicillin allergy:
  • Clindamycin IM/IV, 600 mg 1 one hour before the procedure.
The NICE review noted the lack of a consistent association between interventional procedures and development of infective endocarditis, and that the efficacy of antibiotic prophylaxis is unproven. It further commented that because the antibiotic is not without risk, there is a potential for a greater mortality from severe hypersensitivity than from withholding antibiotics.


When to refer:
  • Where surgery is contemplated.
  • Management of intractable heart failure or other non-responding complications.
  • Pregnancy.