Acute rheumatic fever is an autoimmune response to a previous group A beta-hemolytic streptococcal (GAS) infection causing acute generalized anti-inflammatory response primarily affecting the heart.
It often presents in patients 5-14 years of age and uncommon before 3 years and after 21 years of age.
Patients presenting with acute rheumatic fever are severely unwell, in extreme pain and requires hospitalization.

Rheumatic%20fever%20-%20acute Treatment

Principles of Therapy

Goals of Therapy

  • Provide education for patient and patient’s caregivers
  • Eradication of group A beta-hemolytic Streptococcus (GAS)
  • Symptomatic relief of acute manifestations of ARF
    • Anti-inflammatory drugs is the mainstay for symptomatic management of ARF-associated arthritis and usually continued until all joint symptoms have resolved
    • Management of rheumatic carditis involves early diagnosis and severity assessment with echocardiography, management of heart failure and other complications
    • Prevention of progression of cardiac disease by providing prophylaxis against future GAS infection


  • Give oral Phenoxymethylpenicillin upon suspicion of acute rheumatic fever (ARF) and during the course of diagnosis. Once diagnosis is established, administer Benzathine penicillin G and stop Phenoxymethylpenicillin

Secondary Prevention
Recurrent ARF is defined as 2 major or 1 major with 2 minor or 3 minor manifestations (patients with moderate- to high-risk) plus evidence of previous GAS infection

  • Continuous antimicrobial prophylaxis is recommended in patients with history of rheumatic fever (RF)
  • Prophylaxis of 12 months duration with reevaluation thereafter is recommended for patients with possible RF
    • Reevaluation should include repeat history, physical exam and echocardiography




  • Used to eradicate or prevent Group A streptococcus (GAS) infection
  • Treatment option for patients with penicillin allergy

Benzathine Penicillin G

  • Given to eradicate streptococci and is the 1st dose of penicillin for secondary prophylaxis
  • Drug of choice for acute rheumatic fever (ARF) patients with confirmed GAS not allergic to Penicillin


  • Eg Cephalexin, Cefadroxil
  • Used for the primary prevention and treatment of GAS infection in patients allergic to Penicillin

Macrolides, Oral

  • Eg Erythromycin, Clindamycin, Clarithromycin, Azithromycin, Roxithromycin
  • Used if patient has documented penicillin allergy
  • Recommended once there is suspicion of ARF and continue for 10 days or until ARF is diagnosed and Benzathine penicillin G is administered

Phenoxymethylpenicillin (Penicillin V), Oral

  • Used to eradicate GAS infection, if present
  • Start administration once there is suspicion of ARF and continue for 10 days or until ARF is diagnosed and Benzathine penicillin G is administered

Symptomatic Pharmacotherapy

Rheumatologists, cardiologists, and/or neurologists should be consulted based on the patient’s symptoms. Use of NSAID, salicylates and/or steroids are not recommended until ARF is confirmed as it will prevent development of joint manifestations and suppress acute phase reactants


  • Salicylates and nonsteroidal anti-inflammatory drugs (NSAID)
    • Eg Aspirin, Codeine, Ibuprofen, Naproxen, Paracetamol
    • Used for arthritis or severe arthralgia
    • Paracetamol is recommended as first-line therapy for ARF arthritis pain
    • Naproxen is a treatment option for Aspirin
    • Recommended once ARF is confirmed 
  • Analgesics
    • Paracetamol and codeine are used for arthritis or severe arthralgia if ARF is not yet confirmed and patient is still undergoing diagnosis
    • Patients with mild arthralgia respond well to Paracetamol

Carditis/Heart Failure

  • Diuretics (eg Furosemide, Spironolactone) are used for mild-moderate heart failure
  • Angiotensin-converting-enzyme (ACE) inhibitors (eg Captopril, Enalapril, Lisinopril) may be used for more severe  heart failure [dysfunctional left ventricular (LV) function]
  • Corticosteroids (eg Prednisone, Prednisolone) are indicated for severe carditis, heart failure, or pericarditis with effusion
  • Digoxin is administered if atrial fibrillation or heart failure is present
  • Please see Heart Failure - Acute and Heart Failure - Chronic disease management charts in MIMS Cardiology

Sydenham’s chorea

  • Start pharmacotherapy when symptoms interfere with normal activities
    • Sedatives or anticonvulsants (eg Carbamazepine, Valproic Acid, Haloperidol, Chlorpromazine and Diazepam), may be used to relieve symptoms


  • Paracetamol is indicated for fever
Secondary Prevention
Benzathine Benzylpenicillin G
  • Recommended 1st-line antibiotic regimen for the prevention of recurrent RF
  • An intramuscular dose every 4 weeks is recommended

Oral Anti-infectives


  • The only oral anti-infective recommended for the prevention of recurrent RF
  • 2nd-line antibiotic regimen for the prevention of ARF next to Penicillin G

Sulfadiazine or Sulfafurazole

  • Recommended only in patients allergic to penicillins


  • Erythromycin, Clarithromycin, or Azithromycin may be used in patients allergic to penicillins, Sulfadiazine, and Sulfafurazole

Duration of Prophylaxis

  • RF patients with persistent valvular disease should receive prophylaxis for 10 years or until 40 years old, whichever is longer
    • Lifelong prophylaxis may be recommended in high-risk patients
  • RF patients with carditis but no residual heart disease may receive prophylaxis for 10 years or until 21 years old, whichever is longer
  • RF patients without carditis may continue prophylaxis up to 5 years or until 21 years old, whichever is longer
  • Discontinuation of prophylaxis should be thoroughly discussed with the patient and his/her family with emphasis on risks vs benefits

Non-Pharmacological Therapy

Initial episode of acute rheumatic fever (ARF) requires hospitalization for thorough clinical assessment, observation and guided management

General care

  • Examine daily for pattern of arthritis, presence of heart murmur, choreiform movements, skin rash and subcutaneous nodules
  • Seek medical attention upon the 1st sign of pharyngitis
  • Document cardiac signs and symptoms with carditis
  • Educate and involve family members
  • Advise nutritious diet without restrictions except in patients with congestive heart failure (CHF)
    • Patients with CHF should follow a fluid-limited and sodium-restricted diet
  • Potassium supplementation may be necessary due to mineralocorticoid effect of corticosteroid and diuretics, if used

Bed Rest and Indoor Ambulation

  • Recommended duration of bed rest
    • 1-2 weeks with arthritis alone
    • 2-3 weeks with mild carditis, 4-6 weeks with moderate carditis, 2-4 months with severe carditis
  • Recommended duration of indoor ambulation
    • 1-2 weeks after hospital discharge with arthritis alone
    • 2-3 weeks after hospital discharge with mild carditis, 4-6 weeks after hospital discharge with moderate carditis, 2-4 months after hospital discharge with severe carditis
  • Do not allow full activity until the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have returned to normal
  • Patients with Sydenham’s chorea may require a wheelchair and should be on homebound instruction until abnormal movements resolve
  • No physical restrictions are needed after the initial episode subsides in the absence of carditis
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Cardiology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
05 Feb 2021

Primary immunodeficiency disease (PIDD) and allergies are two groups of conditions related to the immune system. However, they are uniquely different in terms of symptoms and treatment.

Pearl Toh, 26 Nov 2020
Inhaled corticosteroid (ICS) should be the mainstay of long-term asthma management — such is the key message of the latest Singapore ACE* Clinical Guidance (ACG) for asthma, released in October 2020.
Stephen Padilla, 22 Feb 2021
Treatment with intravenous (IV) dexamethasone for 10 days significantly reduces duration of mechanical ventilation at 28 days and 60-day mortality in patients with established moderate-to-severe acute respiratory disease syndrome (ARDS) compared with no dexamethasone, results of the DEXA-ARDS trial have shown.
6 days ago
A recent modelling study has found that expanding current pre-exposure prophylaxis (PrEP) programmes and improving adherence rates can substantially lower HIV incidence among men who have sex with men (MSM).