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Preventing Rheumatic Fever: A New Guideline from the AHA

Correct diagnosis and antibiotic treatment of group A streptococcal pharyngitis is necessary for primary prevention of rheumatic fever.

The American Heart Association (AHA) has released a new guideline, endorsed by the American Academy of Pediatrics, which focuses on the prevention of rheumatic fever (RF) and on diagnosis and treatment of acute group A streptococcal (GAS) pharyngitis. Also included in the scientific statement are prophylaxis recommendations for recurrent RF and bacterial endocarditis and discussion of poststreptococcal reactive arthritis and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Although much of the information is not new, the report confirms many recommendations in the AAP Committee on Infectious Diseases’ Red Book. Highlights of the report include the following:

— One third of acute RF episodes result from streptococcal infections that are not evident.

— GAS pharyngitis primarily affects children between ages 5 and 15 years. Infants with GAS infections might present with excoriated nares or purulent nasal discharge. Acute RF is rare in children younger than 3 years.

— Microbiological confirmation is necessary to differentiate GAS pharyngitis from pharyngitis caused by other pathogens. Neither rapid antigen tests nor traditional throat culture can differentiate between people who have GAS infection and those who are carriers.

— Antigen tests are very specific, but sensitivity is unacceptably low. If a patient has a negative rapid test but the clinician has a high index of suspicion for GAS pharyngitis, a culture should be performed.

— Treatment is indicated for patients with acute pharyngitis and either a positive antigen test or a positive culture. In general, follow-up cultures are not recommended.

— Recommended treatments for primary prevention of RF are the following:

• Penicillin V (250 mg for children 27 kg or 500 mg for children >27 kg 2 to 3 times/day for 10 days)
  
• Amoxicillin (50 mg/kg once daily [maximum, 1 g] for 10 days)
  
• Benzathine penicillin G (1 dose of 600,000 U for children 27 kg or 1,200,000 U for patients >27 kg)
  

— Recommended treatments for patients allergic to penicillin are the following:

• Clindamycin (20 mg/kg/day divided in 3 doses [maximum, 1.8 g/day] for 10 days)
  
• Azithromycin (12 mg/kg/day [maximum dose, 500 mg/day] for 5 days)
  
• Clarithromycin (15 mg/kg/day divided in 2 doses [maximum, 250 mg twice per day] for 10 days)
  

— Repeated courses of antibiotics are rarely indicated in asymptomatic children who continue to be culture positive for GAS.

Comment: This report highlights a number of important points: GAS pharyngitis is one of the few infectious diseases in which penicillin V can be administered twice daily and amoxicillin once daily. If a rapid antigen test is negative but the pretest probability is high (e.g., the patient has sudden onset of sore throat, fever, and pharyngeal exudate), a culture should be performed. Acute RF and the common signs and symptoms of GAS pharyngitis are rare in children younger than 3 years, so you can be more selective about culturing than in older children.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine April 1, 2009

Citation(s):

Gerber MA et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2009 Mar 24; 119:1541.

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Reader Remarks:

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• Culture for GAS
  HAI PHUOC LE, EDMONTON,ALBERTA,CANADA, 3 Apr 2009 9:14 AM EST
  If pretest probability is high, why should culture ( or rapid antigen test ) be performed /
• adults and amoxicilline
  jasna mv, 12 Apr 2009 3:46 AM EST
  so 1gr once a day if they have more then 20kg even if they have 100kg? is that correct?
• Timing
  werner kaiser, practician, 12 Apr 2009 1:02 PM EST
  after taken culture start with antibiotic therapy instantly?
• Response to queries
  Howard Bauchner, BUSM and Associate Editor, Journal Watch Pediatrics and Adolescent Medicine, 14 Apr 2009 11:47 AM EST
  1. Guidelines still suggest a positive rapid strept or culture - even if high pretest probability; would never excede 50-75%... [more]
• strep treatment
  Sydney R Sewall, Kennebec Pediatrics, 1 Jan 2010 1:23 PM EST
  What the cephalexin vs. penicillin "controversy" -- ie. the empirical evidence (metaanalysis) suggesting lower failure rate with cephalexin?