Rheumatic Fever/RF & Rheumatic Heart Disease : Prevention of Recurrence

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Cardiology in Children

RF/RHD

Pediatrics Cardiology in Children

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Results

RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE (RF/RHD)

Related topics

Predisposing Factors and Pathogenesis of RF/RHD

Clinical Features-Major and Other Manifestations of RF/RHD

Laboratory Investigations and Differential Diagnosis of RF/RHD

Treatment of RF/RHD

Prognosis Sequelae and Cardiac Lesion Progression for RF/RHD

Dr J. R. Kamat
Professor of Pediatrics
Head of Department of Pediatrics
KEM Hospital

Prevention of recurrence and advise during follow up :

Secondary parenteral prophylaxis with benzathine penicillin has practically eliminated recurrence when taken regularly. It has decreased attack rate, decreased worsening of cardiac involvement, CCF and deaths. Monthly schedule has been changed to 3 weekly as many patients in developing countries had recurrence on 4 weekly prophylaxis. Recurrence has reduced after the change. Plasma penicillin levels have corroborated the above finding amongst Indian children.
Other drugs which are used for secondary prophylaxis are :
- Sulphadiazine - 0.5gm OD for <30kg & 1gm for>30kg.
- Oral penicillin - 125 mg BD (It is less effective than sulphadiazine.) However, it has several disadvantages:
  - BD dosage
  - more costly
  - emergence of drug resistant streptococci in the mouth
  - increased risk of IE
Compliance with any kind of prophylaxis is a problem. Prophylaxis is given for a minimum period of 5 years if there is no cardiac involvement. It is preferably given till mid adulthood to include the child-bearing age. It is given for life in patients with heart disease.
Close and long term follow up is essential for continued Benzathine Penicillin Prophylaxis.
Advise should be given regarding anti-infective endocarditis prophylaxis before any minor or major surgical procedure
including minor suturing and removal of tartar from teeth etc. (See Annexure I.)
Comprehensive support with availability of social worker, psychologist is ideal for better follow up, compliance, etc.
Periodic 2D ECHO to assess the Cardiac status should be done so that surgical intervention can be advised before complications arise.

Complications and Sequelae:
- Recurrence - Rheumatic fever with carditis
- Established valvular lesions.
- Congestive cardiac failure.
- Pulmonary hypertension.
- Infective endocarditis.
- Pulmonary embolism.
- Moderate anemia.
- Growth retardation
- Chronically dilated heart with mechanical failure due to reduced ejection fraction leading to easy fatigability and compromised quality of life.

Most admissions are for one of the above situations. These need to be handled appropriately. Close follow up ensures that the worsening of RHD and its complication do not occur and if they do, the damage is minimized.

Point to note:

In established heart disease, recurrence of carditis may present as congestive heart failure. Both the carditis as well as congestive failure need to be treated. Often the CCF is refractory especially in presence of a regurgitant lesion. In this situation, beside the management of CCF (Bed rest, salt and fluid restriction, diuretics and digoxin), it is essential to give afterload reducing substance like ACE inhibitors (Captopril). In refractory cases, ionotropic support with dopamine may have to be considered.

Annexure I :

Infective Endocarditis Prophylaxis :

*For almost all patients, the drug is given one hour before the procedure unless mentioned otherwise.

Oral Amoxicillin 50mg/kg, it may be given IM or IV. Adult dose: 2 gms.
For patients with Amoxicillin/ Ampicillin allergy :
- Oral Clindamycin 20 mg/kg. Adults: 600 mg.
  
  OR
- Oral Cephalexin or Cefadroxil 50mg/kg. Adult dose: 2.0gm
  
  OR
- Oral Azithromycin or Clarithromycin 15 mg/kg. Adult dose: 500 mg
  
  OR
- IV Clindamycin 20mg/kg. Adult dose: 600 mg
  
  OR
- IV Cefazolin 2.5 mg/kg. Adult - 1.0 gm
If gastrointestinal or genitourinary surgery is contemplated, then following can be give:
- In patients with high risk :
  
  IV Ampicillin/ Amoxicillin 50 mg/ kg + Gentamycin 1.5 mg/kg 30 minutes before the procedure and 6 hours after the procedure.
- For high risk patients with Amoxicillin allergy :
  
  IV Vancomycin 20 mg/kg ( Adult 1gm) over 1-2 hours + IV Gentamycin 1.5 mg/kg 30 minutes before the procedure.
- For moderate risk surgery :
  
  Only IV or IM Amoxicillin 50 mg/kg ( Adult 1gm)
- For moderate risk patients with Amoxicillin allergy :
Vancomycin 20 mg/kg (Adult 1gm) over 1-2 hours.