Rheumatic fever primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]; Anthony Gallo, B.S. [4]


Effective measures for the primary prevention of rheumatic fever include reducing exposure to Group A beta-hemolytic streptococci and antibiotic prophylaxis for streptococcal pharyngitis. Intramuscular benzathine penicillin G and oral penicillin V are the recommended antibiotics in treatment of group A streptococcal infection in absence of penicillin allergy.

Primary Prevention

Effective measures for the primary prevention of rheumatic fever include reducing exposure to Group A beta-hemolytic streptococci, which requires dramatic improvements in housing, hygiene infrastructure and access to health care for individuals in the developing countries.[1] Most streptococcal pharyngitis, when treated with appropriate antibiotics, prevents acute rheumatic fever.[2] Unfortunately, at least one third of episodes of acute rheumatic fever result from unapparent streptococcal infections.[3] In addition, some symptomatic patients do not seek medical care; in these instances, rheumatic fever is not preventable.

Antimicrobial Regimens

  • Preferred regimen (1): Penicillin V 500 mg PO q6-8h for 10 days
  • Preferred regimen (2): Amoxicillin 50 mg/kg PO qd for 10 days (maximum dose 1 g)
  • Preferred regimen (3): Penicillin G 0.6 MU IM single dose (≤27 kg / ≤60 lb); 1.2 MU IM single dose (>27 kg / >60 lb)
  • Alternative regimen (1): Cephalexin 500 mg PO bid for 10 days
  • Alternative regimen (2): Cefadroxil 1 g PO qd for 10 days
  • Alternative regimen (3): Clindamycin 20 mg/kg/day PO tid for 10 days (maximum dose 1.8 g/day)
  • Alternative regimen (4): Azithromycin 12 mg/kg PO qd for 5 days (maximum dose 500 mg/day)
  • Alternative regimen (5): Clarithromycin 15 mg/kg/day PO bid for 10 days (maximum 500 mg/day)


  1. Robertson KA, Volmink JA, Mayosi BM (2005). "Antibiotics for the primary prevention of acute rheumatic fever: a meta-analysis". BMC Cardiovasc Disord. 5 (1): 11. doi:10.1186/1471-2261-5-11. PMC 1164408. PMID 15927077.
  2. DENNY FW, WANNAMAKER LW, BRINK WR, RAMMELKAMP CH, CUSTER EA (1950). "Prevention of rheumatic fever; treatment of the preceding streptococcic infection". J Am Med Assoc. 143 (2): 151–3. PMID 15415234.
  3. Dajani AS (1991). "Current status of nonsuppurative complications of group A streptococci". Pediatr Infect Dis J. 10 (10 Suppl): S25–7. PMID 1945592.
  4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST; et al. (2009). "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: endorsed by the American Academy of Pediatrics". Circulation. 119 (11): 1541–51. doi:10.1161/CIRCULATIONAHA.109.191959. PMID 19246689.