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©2007 World Heart Federation … Updated October 2008
Diagnosis and Management of Acute Rheumatic Fever
and
Rheumatic Heart Disease
©2007 World Heart Federation … Updated October 2008
Secondary Prophylaxisto prevent recurrent ARF
©2007 World Heart Federation … Updated October 2008
This presentation is intended to support the Curriculum for training health workers and others involved in the diagnosis and management of acute rheumatic fever and rheumatic heart disease.
It has been made possible thanks to the support of the Vodafone Group Foundation and the International Solidarity, State of Geneva, and the ongoing support of Menzies School of Health Research, Caritas Australia, Fiji Water Foundation, Cure Kids and Accor Hospitality.
©2007 World Heart Federation … Updated October 2008
Secondary Prophylaxis
Secondary prophylaxis is the terms used to describe regular delivery of antibiotics to
prevent recurrence of GAS infection and subsequent development of ARF.
Secondary prophylaxis is recommended for people who have had ARF, or who have
RHD to
– Prevent further Group A Streptococcal infections
– Prevent recurrence ARF
– Prevent the development or worsening of RHD
– Reduce the severity of RHD
– Help reduce the risk of death from severe RHD.
©2007 World Heart Federation … Updated October 2008
Standard Treatment
Benzathine penicillin G
1,200,000 units for ALL people ≥30kg
600,000 units for children <30kg
Every 3 or 4 weeks (by intramuscular injection)
Penicillin V
Given if needles cannot be given due to excessive bleeding
250mg twice daily (by mouth)
Erythromycin
Given if Penicillin allergy has been confirmed by a Medical Officer
250mg twice daily (by mouth)
©2007 World Heart Federation … Updated October 2008
Considerations
When should secondary prophylaxis be considered?– ARF confirmed by the Revised Jones Criteria
– RHD confirmed on echocardiogram
– ARF or RHD not confirmed by the Revised Jones Criteria, but considered highly ‘probable’
Precautions– Do not give Benzathine Penicillin G or Penicillin V if there is a documented Penicillin allergydocumented Penicillin allergy
– Drug reactions are rare
Continue secondary prophylaxis during pregnancy
Continue secondary prophylaxis during anticoagulation (e.g. with Warfarin)
©2007 World Heart Federation … Updated October 2008
– Age at first diagnosis of ARF (or RHD)
– Severity of disease
– If carditis was present with first ARF
Disease Classification Duration of secondary prophylaxis
ARF (no carditis)
Minimum of 5 years after last ARF, or Until age 18 years (whichever is longer)
Mild-moderate RHD(or healed carditis)
Minimum of 10 years after last ARF, or Until age 25 years (whichever is longer)
Severe RHD and after Surgery
Continue for life
– Time (years) since last ARF illness
– Ongoing risk factors (e.g. level of poverty)
– If medication is received regularly
Length of time for secondary prophylaxis depends on a number of factors including
Guidelines for Secondary Prophylaxis
** Secondary prophylaxis guidelines may vary **
World Health Organisation guidelines for secondary prophylaxis duration:
©2007 World Heart Federation … Updated October 2008
Secondary Prophylaxis should only be ceased following:
No ARF signs/symptoms for at least 5 years,
and
Medical Specialist review (Paediatrician / Physician / Cardiologist)
and
Echocardiogram to establish presence & severity of RHD (if available)
Ceasing Secondary Prophylaxis
©2007 World Heart Federation … Updated October 2008
Assessment and Preparation
– Confirm person’s identity
– Review known drug allergies
– Discuss and record any recent ARF or RHD symptoms (refer to medical officer if required)
– Obtain consent for injection
Benzathine Penicillin injection delivery
©2007 World Heart Federation … Updated October 2008
Check medication name, dose and expiry date
Prepare medication according to the product information
– Administer 1,200,000 units for all persons ≥ 30kg
– Administer 600,000 units for small children <30kg
Administer with a size 23-gauge needle
Dispose of used needles and syringes in a puncture-proof container.
Use a new needle and syringe for each injection
Administer medication immediately after preparation
Benzathine Penicillin injection delivery
©2007 World Heart Federation … Updated October 2008
Documentation
Record in the Benzathine penicillin injection book and/or medical notes
– Dose and batch number
– Date given and date next due
– Signature (of person giving injection)
Record next date due on a reminder card (if applicable)
©2007 World Heart Federation … Updated October 2008
1. Record the number of injections PRESCRIBED for the full year
– 13 injections should be given each year if prescribed every 4 weeks
– 17 injections should be given each year if prescribed every 3 weeks
2. Count the number of injections GIVEN in the full year
3. Calculate the number of injections GIVEN (10) divided by the number
PRESCRIBED (13) and multiply by 100.
EXAMPLE: If 13 injections are PRESCRIBED, and 10 were GIVEN:
(10 ÷ 13) x 100 = 77% RECEIVED
In this example, 77% of injections were RECEIVED for the individual for the year.
Calculating Injection Delivery
©2007 World Heart Federation … Updated October 2008
Receiving less than 80% of injections places an individual at higher risk of recurrent ARF– Follow-up may be required
If injections were PRESCRIBED for the full year but none were GIVEN, record 0%.
Receiving less than 50% of injections places an individual at extreme risk of recurrent ARF
and progression of RHD
– Immediate intervention is required for this individual.Immediate intervention is required for this individual.
Notes on Injection Delivery
©2007 World Heart Federation … Updated October 2008
Factors affecting Injection Delivery
Relationship between the person with ARF/RHD & the health system
Education of the person, family & health workers
Person / family refusing treatment
Person forgetting treatment
Difficulty traveling to health facility
Pain and fear of injections
Health staff workloads and priorities
Alternative therapy use / distrust of health service
©2007 World Heart Federation … Updated October 2008
Strategies to improve Injection DeliveryAppoint a dedicated staff member at each clinic to oversee secondary prophylaxis
coordination
Identify people who need secondary prophylaxis
Identify local health facility for each person
Develop systems for follow-up
Provide ongoing education for people who require injections and their families
Communicate with local RHD programme and other health service providers
Reduce injection pain
Discuss alternative therapy issues
©2007 World Heart Federation … Updated October 2008
Symptoms
– Skin rash
– Itchy eyes
Treatment
Antihistamine (oral or injection)
Penicillin Allergy
©2007 World Heart Federation … Updated October 2008
Symptoms
– Wheezing
– Hives
– Itching
– Swelling of the face and lips
– Difficulty breathing
– Vomiting
– Falling Blood pressure
– Loss of consciousness
– Cardiac arrest
Anaphylaxis
Treatment
Adrenaline (subcutaneous injection)
©2007 World Heart Federation … Updated October 2008
Summary
Antibiotics need to be present in the body at all times to help prevent GAS infections and
prevent recurrent ARF
Benzathine penicillin injections should be given unless there are contraindications to
injections or documented penicillin allergy
Medical Specialist review is required before ceasing secondary prophylaxis
Strategies to improve secondary prophylaxis delivery:
– Good relationships between community and health staff
– Education for the community and health staff
– Systems for follow-up
– Communication between health services
– Reduce injection pain
Document Benzathine Penicillin injections and monitor injection delivery