Scenario | Antibiotic choice(s) |
Preferred treatment in endemic areas where IM penicillin is available at low cost |
|
Alternative treatment in nonendemic areas where IM penicillin is unavailable or prohibitively expensive |
|
Confirmed penicillin allergy* |
|
Severe symptomatic RHD¶ |
|
Bleeding problems following IM injection that cannot be addressed |
|
Other barriers to using the preferred treatment that cannot be resolvedΔ |
|
Patients at low risk of recurrence◊ |
|
Breakthrough infection while on prophylaxis |
|
ARF: acute rheumatic fever; EF: ejection fraction; GAS: Group A Streptococcus; IM: intramuscular; NYHA: New York Heart Association; RHD: rheumatic heart disease.
* Penicillin allergy should be verified by history and confirmed with testing by an allergy specialist if available before choosing an alternative to penicillin G benzathine.
¶ This includes patients with severe symptomatic valvular disease, NYHA class III or IV heart failure symptoms, and/or ventricular dysfunction (ie, EF <50%). Oral therapy is preferred for these patients because they can experience vasovagal reactions with IM injections, and this may increase the risk of sudden death.
Δ Additional barriers include patient concerns (eg, extreme needle phobia) that persist despite appropriate counseling and reassurance.
◊ Patients at low risk of recurrence include those who have reached young adulthood and have remained free of ARF attacks for several years.
§ Rates of resistance to clindamycin are high and can be higher than rates of resistance to macrolides. Therefore, when beta-lactams and macrolides cannot be used, knowledge of local resistance rates should guide antibiotic selection or culture with susceptibility testing should be obtained.