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Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease

Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. Secondary Prophylaxis to prevent recurrent ARF.

andrew-barry
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Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease

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  1. Diagnosis and Management of Acute Rheumatic Fever and Rheumatic Heart Disease

  2. Secondary Prophylaxisto prevent recurrent ARF

  3. 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.

  4. 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.

  5. 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)

  6. 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 allergy • Drug reactions are rare Continue secondary prophylaxis during pregnancy Continue secondary prophylaxis during anticoagulation (e.g. with Warfarin)

  7. Guidelines for Secondary Prophylaxis Length of time for secondary prophylaxis depends on a number of factors including • Age at first diagnosis of ARF (or RHD) • Severity of disease • If carditis was present with first ARF • Time (years) since last ARF illness • Ongoing risk factors (e.g. level of poverty) • If medication is received regularly World Health Organisation guidelines for secondary prophylaxis duration: ** Secondary prophylaxis guidelines may vary **

  8. Ceasing Secondary Prophylaxis 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)

  9. Benzathine Penicillin injection delivery 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

  10. Benzathine Penicillin injection delivery 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

  11. 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)

  12. Calculating Injection Delivery • 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 • 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.

  13. Notes on Injection Delivery 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.

  14. 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

  15. Strategies to improve Injection Delivery Appoint 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

  16. Penicillin Allergy Symptoms • Skin rash • Itchy eyes Treatment Antihistamine (oral or injection)

  17. Anaphylaxis Symptoms • Wheezing • Hives • Itching • Swelling of the face and lips • Difficulty breathing • Vomiting • Falling Blood pressure • Loss of consciousness • Cardiac arrest Treatment Adrenaline (subcutaneous injection)

  18. 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 DocumentBenzathine Penicillin injections and monitor injection delivery

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