Abstract
BackgroundRheumatic fever continues to put a significant burden on the health of low socio-economic populations in low and middle-income countries despite the near disappearance of the disease in the developed world over the past century. Antibiotics have long been thought of as an effective method for preventing the onset of acute rheumatic fever following a Group-A streptococcal (GAS) throat infection; however, their use has not been widely adopted in developing countries for the treatment of sore throats. We have used the tools of systematic review and meta-analysis to quantify the effectiveness of antibiotic treatment for sore throat, with symptoms suggestive of group A streptococcal (GAS) infection, for the primary prevention of acute rheumatic fever.MethodsTrials were identified through a systematic search of titles and abstracts found in the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 4, 2003), MEDLINE (1966–2003), EMBASE (1966–2003), and the reference lists of identified studies. The selection criteria included randomised or quasi-randomised controlled trials comparing the effectiveness of antibiotics versus no antibiotics for the prevention of rheumatic fever in patients presenting with a sore throat, with or without confirmation of GAS infection, and no history of rheumatic fever.ResultsTen trials (n = 7665) were eligible for inclusion in this review. The methodological quality of the studies, in general, was poor. All of the included trials were conducted during the period of 1950 and 1961 and in 8 of the 10 trials the study population consisted of young adult males living on United States military bases. Fixed effects, meta-analysis revealed an overall protective effect for the use of antibiotics against acute rheumatic fever of 70% (RR = 0.32; 95% CI = 0.21–0.48). The absolute risk reduction was 1.67% with an NNT of 53. When meta-analysis was restricted to include only trials evaluating penicillin, a protective effect of 80% was found (Fixed effect RR = 0.20, 95% CI = 0.11–0.36) with an NNT of 60. The marginal cost of preventing one case of rheumatic fever by a single intramuscular injection of penicillin is approximately US$46 in South Africa.ConclusionAntibiotics appear to be effective in reducing the incidence of acute rheumatic fever following an episode of suspected GAS pharyngitis. This effect may be achieved at relatively low cost if a single intramuscular penicillin injection is administered.
Highlights
Rheumatic fever continues to put a significant burden on the health of low socioeconomic populations in low and middle-income countries despite the near disappearance of the disease in the developed world over the past century
The use of this single criterion for the diagnosis of group A streptococcal (GAS) infection was supported by a study estimating that 70–90% of patients admitted to army hospitals around the same time period with streptococcal tonsillitis or pharyngitis presented with exudate on their tonsils or oropharynx [26]
Twenty nine of 3996 (0.73%) patients taking an antibiotic, and 89 of 3669 (2.4%) patients receiving no antibiotic developed acute rheumatic fever 1–2 months following a suspected streptococcal sore throat infection. These findings suggest that administering antibiotics to a patient with a sore throat and symptoms suggestive of GAS infection, who has no history of rheumatic fever, will reduce his or her risk of acute rheumatic fever by almost 70%
Summary
Rheumatic fever continues to put a significant burden on the health of low socioeconomic populations in low and middle-income countries despite the near disappearance of the disease in the developed world over the past century. Antibiotics have long been thought of as an effective method for preventing the onset of acute rheumatic fever following a Group-A streptococcal (GAS) throat infection; their use has not been widely adopted in developing countries for the treatment of sore throats. We have used the tools of systematic review and meta-analysis to quantify the effectiveness of antibiotic treatment for sore throat, with symptoms suggestive of group A streptococcal (GAS) infection, for the primary prevention of acute rheumatic fever. The global burden of disease caused by rheumatic fever currently falls disproportionately on children living in the developing world. Rheumatic heart valve disease causes 400,000 deaths annually mainly among children and young adults living in developing countries. The recent resurgence of rheumatic fever in middle-class families in some parts of the economically developed world is a reminder that even in industrialised countries, there is no room for complacency [9,10]
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