Rheumatic Fever

Clinical Description

Rheumatic fever is an inflammatory disease that can involve the heart, joints, skin and brain.

ACUTE ATTACK

Treatment

• Give Benzathine Penicillin 1.2MU IM single dose
• Children <30 kg: Benzathine Penicillin 600,000 units

Alternatively, if compliance can be ensured:

• Phenoxymethylpenicillin 250 mg every 6 hourly for 10 days
• Children: Phenoxymethylpenicillin 12.5 mg/kg/dose

Alternatively, if penicillin allergy:

• Erythromycin 500mg every 8hrs for 10 days

ACUTE CARDITIS

• Strict bed rest until carditis has resolved

Adults and Children

Treatment

• Give Aspirin 25mg/kg, preferably after food, 6 hourly
• Reduce dose if tinnitus or other toxic symptoms develop
• Continue treatment with this until fever and joint inflammation are controlled
• Then reduce dose gradually over a 2week period

If symptoms recur:

• Restart full dose

In severe carditis with heart failure and not responding to aspirin:

• Add Prednisolone 2 mg/kg OD
• Reduce dose gradually after 3-4 weeks
• Treat heart failure

CHOREA

Treatment

Adults and Children

• Give Haloperidol 25 micrograms/kg every 8hrs

PROPHYLAXIS OF RHEUMATIC FEVER

Prevention of further attacks

• Continue treatment until at least age 25

Treatment

• Give Benzathine Penicillin 1.2 MU IM monthly. Children < 30 kg: 600,000 units/dose

Alternative if compliance can be ensured:

• Give Phenoxymethylpenicillin 250mg bd

Alternative if penicillin allergy:

• Give Erythromycin 500 mg daily
• Children <30 kg: 250mg

PROPHYLAXIS OF BACTERIAL ENDOCARDITIS

• Needed to prevent bacterial endocarditis in those with previous rheumatic fever or any heart valve abnormalities of other cause.

Before Dental Extraction

Prophylaxis in Adults and Children > 30 kg:

• Give Amoxycillin 3g oral taken 1 hour before the dental procedure

Alternatively, if penicillin allergy:

• Give Erythromycin 1.5g taken 1 hour before the procedure and 500 mg 6 hourslater

Prophylaxis in Children > 30 kg:

• Give Amoxycillin 50 mg/kg taken 1 hour before dental procedure, and repeated 6 hours later

Alternatively, if penicillin allergy:

• Give Clindamycin 600mg, orally, taken 1 hour before the procedure and 300mg 6 hours later

Prophylaxis in Children > 30kg:

• Give Clindamycin 600mg IM/IV 30min prior to the procedure followed by 300mg 6 hourly.

(20mg/kg for children) OR

• Give Ceftriaxone 1g IV prior to the procedure or 50mg/kg

For high-risk patients add:

Gentamicin 1.6mg/kg prior to the procedure OR

Vancomycin 1g IV (20mg/kg/IV for children <l0 years old) prior to the procedure.

PROPHYLAXIS BEFORE OTHER PROCEDURES

For genito-urinary surgery or instrumentation:

• Give Amoxycillin 1g IV or IMplus
• Give Gentamycin 2mg/kg IV or IM 30 minutes before the procedure, then
• Give Amoxycillin 500mg taken 6 hours later

Alternative if penicillin allergy:

• Give Erythromycin 500mg every 12hrs for 48 hours, instead of Amoxicillin
• For obstetric and gynecological procedures
• Not required except for those with prosthetic heart valves who should receive prophylaxis as for dental procedures

CELLULITIS AND TROPICAL PYOMYOSITIS

• Treatment for cellulitis is both medical and surgical
• Medical treatment may prevent abscess formation at the start of infection, when the muscle is swollen, hot and painful
• Immobilize and give:

Treatment

Adult and children:

• Give Flucloxacillin 1g IV 6 hourly for at least 14 days plus,
• Give Ciprofloxacin 500mg orally 12 hourly for 5-7 days

If penicillin allergic:

• Give Ceftriaxone 2g IV daily for 2 weeks

Note: For Pyomyositis, perform surgical treatment (abscess drainage) when the swelling becomes fluctuant, alongside antibiotics