Management Of Acute Rheumatic Fever Research Articles

Sudan's rheumatic fever and rheumatic heart disease guidelines: a simplified approach in an endemic country.

Rheumatic heart disease (RHD) is a preventable sequelae of group A beta hemolytic streptococcal infection leading to an immune reaction: acute rheumatic fever (ARF) and progressive heart valve dysfunction. RHD is the leading cause of acquired heart disease in children and young adults in Sudan and many low/middle-income countries. In 2018, the World Health Organization (WHO) issued a resolution for RHD mandating that each country adopt updated guidelines for ARF and RHD management. These current guidelines are mainly directed to primary healthcare workers. Sudan's Federal Ministry of Health (FMOH) in collaboration with the WHO East Mediterranean Regional Office (EMRO) assembled a committee for updating RHD guidelines. We conducted a systematic literature search from 2000 to 2022 in National Institute of Health Database (PubMed) under the following titles: streptococcal pharyngitis, acute rheumatic fever, rheumatic heart disease, benzathine penicillin. Best available, evidence-based practices for diagnosis and management of ARF/RHD were selected and adapted to Sudan's situation. The guidelines were critically appraised by the committee then endorsed to the FMOH and WHO EMRO Noncommunicable Disease Departments in January 2023. This paper describes the updated guidelines. Simplified algorithms are provided for diagnosis of bacterial pharyngitis including two clinical criteria: sore throat and the absence of viral symptoms in the target age group. A simplified algorithm for diagnosis and management of ARF is adopted using two levels of diagnosis: suspected case at primary level where penicillin prophylaxis is started and secondary/tertiary care where echocardiography is performed and diagnosis confirmed or excluded. Echocardiography screening is recognized as the standard method for early diagnosis of RHD; however, due to the anticipated limitations, its implementation was not adopted at this time. Streptococcal skin infection is included as a precursor of ARF and a detailed protocol for benzathine penicillin administration is described. The Sudan guidelines for ARF/RHD management were updated. Endorsement of these guidelines to FMOH and WHO EMRO is expected to improve control of RHD in the region.

Comparison of streptococcal serology reporting to ‘The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease’

Comparison of streptococcal serology reporting to ‘The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease’

Diagnosis and management of acute rheumatic fever

Acute rheumatic fever is a nonsuppurative, immune-mediated consequence of group A streptococcal pharyngitis. Recurrent or severe acute rheumatic fever can cause permanent cardiac valve damage and rheumatic heart disease. Universally, the most common major manifestations during the first episode of ARF remain carditis and arthritis. Subclinical carditis now can fulfils a major criterion for ARF in all populations as in revised Jones criteria – AHA 2015. Many of the clinical features of ARF are non-specific, so a wide range of differential diagnoses should be considered. Primary prevention requires accurate recognition and proper antibiotic treatment of GAS pharyngitis. Prevention of recurrent attacks of rheumatic fever (secondary prevention) is the most cost-effective way of preventing further rheumatic heart disease (RHD). Penicillin remains the antibiotic of choice. Intramuscular penicillin is preferred as it is more effective than oral penicillin and results in better compliance.

Positive impact of training rural health workers in identification and prevention of acute rheumatic fever in eastern Uganda.

Diagnosis of acute rheumatic fever (ARF) is mainly clinical. Delayed or missed diagnosis and failure to administer appropriate and timely treatment of ARF leads to rheumatic heart disease (RHD), which could necessitate expensive treatments such as open-heart surgery. Implementation of preventative guidelines depends on availability of trained healthcare workers. As part of the routine support supervision, the Uganda Heart Institute sent out a team to rural eastern Uganda to evaluate health workers' knowledge level regarding management of ARF. Health workers from selected health facilities in Tororo district, eastern Uganda, were assessed for their knowledge on the clinical features and role of benzathine penicillin G (BPG) in the treatment and prevention of ARF recurrence. Using the RHD Action Needs assessment tool, we generated and administered a pre-test, then conducted training and re-administered a post-test. Eight months later, health workers were again assessed for knowledge retention and change in practices. Statistical analysis was done using Stata version 15. During the initial phase, 34 of the 109 (31%) health workers passed the pre-test, indicating familiarity with clinical features of ARF. The level of knowledge of BPG use in ARF was very poor in all the health units [25/109 (22.6%)] but improved after training to 80%, as shown by the chi-squared test ( χ2 = 0.000). However, retention of this knowledge waned after eight months and was not significantly different compared to pre-training (χ2 ≥ 0.2). A critical knowledge gap is evident among health workers, both in awareness and treatment of ARF, and calls for repetitive training as a priority strategy in prevention.

The evidence that rheumatic heart disease control programs in Australia are making an impact

ObjectiveRheumatic heart disease (RHD) comprises heart-valve damage caused by acute rheumatic fever (ARF). The Australian Government Rheumatic Fever Strategy funds RHD Control Programs to support detection and management of ARF and RHD. We assessed epidemiological changes during the years of RHD Control Program operation. MethodsLinked RHD register, hospital and death data from four Australian jurisdictions were used to measure ARF/RHD outcomes between 2010 and 2017, including: 2-year progression to severe RHD/death; ARF recurrence; secondary prophylaxis delivery and earlier disease detection. ResultsDelivery of secondary prophylaxis improved from 53% median proportion of days covered (95%CI: 46-61%, 2010) to 70% (95%CI: 71-68%, 2017). Secondary prophylaxis adherence protected against progression to severe RHD/death (hazard ratio 0.2, 95% CI 0.1-0.8). Other measures of program effectiveness (ARF recurrences, progression to severe RHD/death) remained stable. ARF case numbers and concurrent ARF/RHD diagnoses increased. ConclusionsRHD Control Programs have contributed to major success in the management of ARF/RHD through increased delivery of secondary prevention yet ARF case numbers, not impacted by secondary prophylaxis and sensitive to increased awareness/surveillance, increased. Implications for public healthRHD Control Programs have a major role in delivering cost-effective RHD prevention. Sustained investment is needed but with greatly strengthened primordial and primary prevention.

Rheumatic Heart Disease Causes Heart Failure. How is It Treated?

Highlight: Rheumatic heart disease is among a leading cause of heart failure in school-age children. It discusses how to proper manage rheumatic heart damage Abstract: Rheumatic heart disease is the leading cause of heart failure in school-age children, affects 30 million people worldwide, and is still prevalent, especially in developing countries. Rheumatic heart disease was the result of untreated acute rheumatic fever. Knowledge of the proper management should be encouraged in those with rheumatic fever to halt the progression of cardiac damage that can lead to heart failure. This article discusses one such case. Case Summary. A 13-year-old girl complained of breathlessness during the activity, which improved with rest. She had a history of multiple joint pain and recurrent upper respiratory infection, which was not treated with antibiotics. On physical examination, the blood pressure was 90/60 mmHg, heart rate 128 bpm, facial and palpebral swelling, and the jugular vein pressure increased 5+3 cm H2O. The heart sound was S1>S2, regular with gallop and murmur in mitral, aortic, pulmonary, and tricuspid valves. Hepatomegaly and swelling of both lower extremities were discovered. Laboratories tests found ASTO 400 IU/ml. Chest X-Ray showed cardiomegaly. Echocardiography showed the regurgitation of mitral, aortic, tricuspid, and pulmonary valves. Discussion. The patient was diagnosed with heart failure fc. NYHA II ec rheumatic heart disease and treated with penicillin benzathine 1.2 units, furosemide injection 30 mg b.i.d, spironolactone 25 mg b.i.d, tenace 5 mg q.d, and prednisone 5-4-4 mg t.i.d. Adequate management of acute rheumatic fever can reduce the recurrence, prevent rheumatic heart disease and cardiac deterioration, and improve quality of life.

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

Roadmap to incorporating group A Streptococcus molecular point-of-care testing for remote Australia: a key activity to eliminate rheumatic heart disease.

The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) cause significant morbidity and premature mortality among Australian Aboriginal and Torres Strait Islander peoples. RHDAustralia has produced a fully updated clinical guideline in response to new knowledge gained since the 2012 edition. The guideline aligns with major international ARF and RHD practice guidelines from the American Heart Association and World Heart Federation to ensure best practice. The GRADE system was used to assess the quality and strength of evidence where appropriate. The 2020 Australian guideline details best practice care for people with or at risk of ARF and RHD. It provides up-to-date guidance on primordial, primary and secondary prevention, diagnosis and management, preconception and perinatal management of women with RHD, culturally safe practice, provision of a trained and supported Aboriginal and Torres Strait Islander workforce, disease burden, RHD screening, control programs and new technologies. Key changes include updating of ARF and RHD diagnostic criteria; change in secondary prophylaxis duration; improved pain management for intramuscular injections; and changes to antibiotic regimens for primary prevention. Other changes include an emphasis on provision of culturally appropriate care; updated burden of disease data using linked register and hospitalisations data; primordial prevention strategies to reduce streptococcal infection addressing household overcrowding and personal hygiene; recommendations for population-based echocardiographic screening for RHD in select populations; expanded management guidance for women with RHD or ARF to cover contraception, antenatal, delivery and postnatal care, and to stratify pregnancy risks according to RHD severity; and a priority classification system for presence and severity of RHD to align with appropriate timing of follow-up.

Clonidine for pain-related distress in Aboriginal children on a penicillin regimen to prevent recurrence of rheumatic fever.

Indigenous children and adolescents in Australia and globally bear the burden of acute rheumatic fever (ARF). It has been virtually eliminated in well-resourced, developed settings. ARF is an autoimmune response to infection with group A Streptococcus. The mainstay of management is long-acting intramuscular penicillin injections to prevent recurrence of ARF and development of rheumatic heart disease (RHD), comprising valvular pathology and attendant complications. In Australia, penicillin injections are currently prescribed every 28 days for 5-10 years after diagnosis of ARF, depending on cardiac involvement. Adherence to this regimen reduces ARF recurrences and RHD progression. 'Days at risk' of ARF recurrence are calculated as the number of days after day 28 that an injection is not received. Adherence to the injection schedule has been reported as difficult in most global locations due to the painful nature of the injections, the long timeframes of the prescription, young age of patients, access problems and costs in some locations. The newly updated Australian guideline on the prevention, diagnosis and management of ARF and RHD has a chapter dedicated to secondary prophylaxis. This chapter takes into account cultural considerations and advises on ways to minimise pain and distress of injections in children such as pain gate strategies, distraction techniques and concurrent injection of local anaesthetic. Some children continue to find the injection regimen traumatising despite strategies to reduce pain and fear. Clinicians providing the injections to children also find the injecting episodes distressing if pain is not effectively minimised. An Aboriginal Community Controlled Health Service in a remote setting in northern Australia addressed the issue of severe trauma of injection episodes experienced by an Aboriginal boy aged 7 years. Usual strategies were not effective, so advice was sought from an expert anaesthetist at a tertiary hospital. As a result, oral clonidine 3 µg/kg was trialled 45 minutes prior to the penicillin injection. Procedural coaching and monitoring protocols specific to administration of clonidine in children under their care were created by the health service. The initial dose of clonidine was delivered with the child as an inpatient. Clonidine was successful in reducing pain related distress and facilitating adherence to the penicillin regimen. Subsequent doses were delivered and monitored in a remote setting by nurses. After 18 months, the boy no longer required clonidine due to his increased coping capacity. A second child was recognised with similar trauma and has been taking clonidine for pre-procedural sedation for 6 months with good effect and no adverse effects. An additional child was similarly prescribed clonidine without success. Failure in that instance was attributed to lack of procedural coaching and receiving the initial dose of clonidine in an emergency department in hurried circumstances. Individualised child-focused and culturally appropriate care in remote settings is feasible: in this instance team planning for use of clonidine and procedural coaching when other measures have failed. However, for children with RHD, or other comorbidities, advice from the child's treating cardiologist is required prior to prescribing clonidine due to possible adverse consequences. These include hypotension and atrioventricular block, which could lead to haemodynamic compromise in the setting of moderate to severe RHD.

Recurrent acute rheumatic fever: a case report

Introduction. It is estimated that about 3% of people untreated for group A streptococcal infection will develop rheumatic fever. In most case, an appropriate treatment with antibiotics will prevent acute rheumatic fever. However, not all case of acute rheumatic fever showed an apparent clinical presentation. Furthermore, some symptomatic patients did not seek medical treatment. These caused rheumatic fever and rheumatic heart disease still prevalent, especially in the developing country. Proper management, according to the latest guideline should be prompted in those individuals to halt the progression of cardiac damage. This article describes one such case.Case Description. A 15-year-old boy with a chief complaint of breathlessness during activity and improved with rest and multiple joint pain. He had a history of recurrent upper respiratory infection, which was not treated with antibiotics. On physical examination, the blood pressure was 110/70 mmHg and heart rate 110 bpm. On cardiac examination, he had holosystolic, and mid-diastolic murmur heard best at the apex. Laboratories test found WBC 15.420/μL, ASTO 400 IU/ml and CRP 48 mg/dL. Chest x-ray showed cardiothoracic ratio of 59% and echocardiography showed left atrial enlargement and left ventricular hypertrophy (ejection fraction 66%), mild mitral stenosis (MVA 1,6 cm2, mean MVG 13 mmHg), and severe mitral regurgitation. The patient was then diagnosed with recurrent acute rheumatic fever and treated with erythromycin 500 mg q.i.d and aspirin 500 mg q.i.d.Conclusion. Adequate management of acute rheumatic fever during and after the acute episode aimed to reduce the recurrence, prevent cardiac deterioration and expected to improve quality of life.

Priorities for improved management of acute rheumatic fever and rheumatic heart disease: analysis of cross-sectional continuous quality improvement data in Aboriginal primary healthcare centres in Australia.

Objective This study investigated the delivery of guideline-recommended services for the management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australian primary healthcare centres participating in the Audit and Best Practice for Chronic Disease (ABCD) National Research Partnership project. Methods ARF and RHD clinical audit data were collected from 63 Aboriginal centres in four Australian jurisdictions using the ABCD ARF/RHD audit tool. Records of up to 30 patients treated for ARF and/or RHD were analysed per centre from the most recent audit conducted between 2009 and 2014. The main outcome measure was a quality of ARF and RHD care composite indicator consisting of nine best-practice service items. Results Of 1081 patients, most were Indigenous (96%), female (61%), from the Northern Territory and Queensland (97%) and <25 years of age (49%). The composite indicator was highest in the 0-14 year age group (77% vs 65-67% in other age groups). Timely injections and provision of client education are important specific areas for improvement. Multiple regression showed age >15 years to be a significant negative factor for several care indicators, particularly for the delivery of long-acting antibiotic injections and specialist services in the 15-24 year age group. Conclusions The results suggest that timely injection and patient education are priorities for managing ARF and RHD, particularly focusing on child-to-adult transition care. What is known about the topic? The burden of rheumatic fever and RHD in some Aboriginal communities is among the highest documented globally. Guideline-adherent RHD prevention and management in primary health care (PHC) settings are critically important to reduce this burden. Continuous quality improvement (CQI) is a proven strategy to improve guideline adherence, using audit cycles and proactive engagement of PHC end users with their own data. Previously, such CQI strategies using a systems approach were shown to improve delivery of ARF and RHD care in six Aboriginal health services (three government and three community controlled). What does this paper add? This paper focuses on the variation across age groups in the quality of ARF and/or RHD care according to nine quality of care indicators across 63 PHC centres serving the Aboriginal population in the Northern Territory, Queensland, South Australia and Western Australia. These new findings provide insight into difference in quality of care by life stage, indicating particular areas for improvement of the management of ARF and RHD at the PHC level, and can act as a baseline for monitoring of care quality for ARF and RHD into the future. What are the implications for practitioners? Management plans and innovative strategies or systems for improving adherence need to be developed as a matter of urgency. PHC professionals need to closely monitor adherence to secondary prophylaxis at both the clinic and individual level. RHD priority status needs to be assigned and recorded as a tool to guide management. Systems strengthening needs to particularly target child-to-adult transition care. Practitioners are urged to keep a quick link to the RHDAustralia website to access resources and guidelines pertaining to ARF and RHD (https://www.rhdaustralia.org.au/arf-rhd-guideline, accessed 3 October 2019). CQI strategies can assist PHC centres to improve the care they provide to patients.

Determinants of poor adherence to secondary antibiotic prophylaxis for rheumatic fever recurrence on Lifou, New Caledonia: a retrospective cohort study

BackgroundIncidence of acute rheumatic fever (ARF) and prevalence of rheumatic heart disease (RHD) in the Pacific region, including New Caledonia, are amongst the highest in the world. The main priority of long-term management of ARF or RHD is to ensure secondary prophylaxis is adhered to. The objectives of this study were to evaluate rates of adherence in people receiving antibiotic prophylaxis by intramuscular injections of penicillin in Lifou and to determine the factors associated with a poor adherence in this population.MethodsWe conducted a retrospective cohort study and we included 70 patients receiving injections of antibiotic prophylaxis to prevent ARF recurrence on the island of Lifou. Patients were classified as “good-adherent” when the rate of adherence was ≥80% of the expected injections and as “poor-adherent” when it was <80%. Statistical analysis to identify factors associated with adherence was performed using a multivariate logistic regression model.ResultsOur study showed that 46% of patients from Lifou receiving antibiotic prophylaxis for ARF or RHD had a rate of adherence <80% and were therefore at high risk of recurrence of ARF. Three independent factors were protective against poor adherence: a household with more than five people (odds ratio, 0.25; 95% confidence interval [CI], 0.08 to 0.75), a previous medical history of symptomatic ARF (odds ratio, 0.20; 95% CI, 0.04 to 0.98) and an adequate healthcare coverage (odds ratio, 0.21; 95% CI 0.06 to 0.72).ConclusionsTo improve adherence to secondary prophylaxis in Lifou, we therefore propose the following recommendations arising from the results of this study: i) identifying patients receiving antibiotic prophylaxis without medical history of ARF to strengthen their therapeutic education and ii) improving the medical coverage in patients with ARF or RHD. We also recommend that the nurse designated for the ARF prevention program in Lifou coordinate an active recall system based on an updated local register. But the key point to improve adherence among Melanesian patients is probably to give appropriate information regarding the disease and the treatment, taking into account the Melanesian perceptions of the disease.

Improving Prevention and Management of Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD)—Yirrkala's Story

Objective: RHD remains an important cause of illness and premature death among Aboriginal people. A project was implemented to develop and trial a structured systems approach to improving prevention and management of ARF and RHD. Administrative processes and systems were embedded resulting in improved health outcomes for RHD patients.

The Management of ARF and RHD in Northern Australia

Objective: In Australia, acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are almost exclusively restricted to Aboriginal Australians and Torres Strait Islander peoples. This project aimed to review the comprehensive management of ARF and RHD in the Kimberley (Western Australia) and far north Queensland to inform ongoing primary and specialist service development.

Acute Rheumatic Fever and Rheumatic Heart Disease—Priorities in Prevention, Diagnosis and Management. A Report of the CSANZ Indigenous Cardiovascular Health Conference, Alice Springs 2011

Three priority areas in the prevention, diagnosis and management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) were identified and discussed in detail: 1. Echocardiography and screening/diagnosis of RHD – Given the existing uncertainty it remains premature to advocate for or to incorporate echocardiographic screening for RHD into Australian clinical practice. Further research is currently being undertaken to evaluate the potential for echocardiography screening. 2. Secondary prophylaxis – Secondary prophylaxis (long acting benzathine penicillin injections) must be seen as a priority. Systems-based approaches are necessary with a focus on the development and evaluation of primary health care-based or led strategies incorporating effective health information management systems. Better/novel systems of delivery of prophylactic medications should be investigated. 3. Management of advanced RHD – National centres of excellence for the diagnosis, assessment and surgical management of RHD are required. Early referral for surgical input is necessary with multidisciplinary care and team-based decision making that includes patient, family, and local health providers. There is a need for a national RHD surgical register and research strategy for the assessment, intervention and long-term outcome of surgery and other interventions for RHD.

Management of acute rheumatic fever—a re-appraisal

Rheumatic fever (RF) has fallen off the radar of many physicians, yet remains a daily challenge to many working in less developed areas of India. Rheumatic fever and rheumatic heart disease (RHD) are diseases of poverty. Overcrowding, low socio-economic status, and illiteracy contribute to the high prevalence. Treatment of the disease is mostly supportive as there is no disease-modifying therapy. Nonsteroidal anti-inflammatory drugs should be withheld until the diagnosis is confirmed, and corticosteroids are an option in severe and acute carditis. Most cases of chorea do not require medication, but use of carbamazepine or sodium valproate is recommended in severe cases. New approaches to primary prevention are needed given the limitations of primary prophylaxis as a population based strategy. The most effective approach for control of RF is secondary prophylaxis, which is best delivered as part of a coordinated control program. Group A streptococcal vaccines are still years away from being available.

Improving Prevention and Management of Acute Rheumatic Fever (ARF) and Rheumatic Heart Disease (RHD)—Yirrkala's Story

review (65% of whom had not had a previous echo), and two thirds had their medication optimised. Conclusion: This service has improved diagnosis and management of heart failure in the community. DOI of original abstract: http://dx.doi.org/10.1016/j.hlc.2011.04.030 DOI of this abstract: http://dx.doi.org/10.1016/j.hlc.2012.07.043

An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are diseases of poverty. They occur at world-record rates in Indigenous Australians, yet individual cases are often poorly managed, and most jurisdictions with high rates of these diseases do not have formal control strategies in place. New Australian guidelines formulated in 2005 by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand for diagnosis and management of ARF and RHD are a valuable resource for clinicians and policymakers. Key recommendations of the guidelines include: New diagnostic criteria for ARF in high-risk populations, including Indigenous Australians, which include echocardiographic evidence of subclinical valvular disease, and polyarthralgia or aseptic monoarthritis as major manifestations. Clear guidance about treatment of ARF. Non-steroidal anti-inflammatory drugs should be withheld until the diagnosis is confirmed, and corticosteroids may be an option in severe acute carditis. Most cases of chorea do not require medication, but use of carbamazepine or sodium valproate is recommended if medication is needed. Clear guidance about dose, dosing frequency and duration of secondary prophylaxis. Benzathine penicillin G is the preferred medication for this purpose. Establishment of a coordinated control program for all regions of Australia where there are populations with high prevalence of ARF and RHD. Key elements and indicators for evaluation are recommended. Active screening and legislated notification of ARF and RHD, where possible. Development of a structured care plan for all patients with a history of ARF or with established RHD, to be recorded in the patient's primary health care record.

Use of Cardiovascular Magnetic Resonance Imaging in Acute Rheumatic Fever

We report a case of acute rheumatic fever in a 46-year-old man diagnosed with the assistance of contrast cardiovascular magnetic resonance imaging. This case demonstrates the use of contrast cardiovascular magnetic resonance imaging as a noninvasive method for detecting carditis and contributing to the diagnosis and management of acute rheumatic fever.

Diagnosis and management of acute rheumatic fever

Acute rheumatic fever (ARF) is a multisystem disease characterised by migratory arthritis (usually affecting the large joints), carditis, chorea, erythema marginatum and subcutaneous nodules (occurring singly or in any combination). It is mainly a disease of childhood and affects children of 5–15 years of age, but no age or race is immune. In the Western European countries the decline in the incidence of ARF became more pronounced after the Second World War, falling to an annual incidence of 12 per 100 000 in Denmark by 1962 and 0.2 per 100 000 in Sweden by 1986. However, ARF remained a significant problem in the United States during this period, with an annual incidence of 26 per 100 000 in Baltimore by 1964. Acceleration of the decline in the United States began in the late 1960 and by 1980, and annual incidence of 0.5 per 100 000 was recorded in Baltimore. Recently, however, several outbreaks of ARF have been reported from different areas in the United States; the recent resurgence of the disease remains unexplained.