Should the Gold Standard of Monthly Benzathine Penicillin Prophylaxis for Rheumatic Fever Be Modified?

Summary

The adequacy of monthly benzathine penicillin prophylaxis, the so-called gold standard for secondary prevention of rheumatic fever, was studied. Starting from 1979, 249 patients with rheumatic fever, randomly allocated to a 3-week (124) or 4-week (125) program, were followed until December 1991. Compliance with each program was comparable. Group A streptococcal infections occurred less frequently in the 3-week than in the 4-week program (P < 0.01). Prophylaxis failure occurred in 2 of 124 patients (0.3 per 100 patient-years) of the 3-week program, and in 10 of 125 (1.3 per 100 patient-years) of the 4-week program (P = 0.015). Of 77 patients with carditis staying in the 3-week program, 47 (61%) lost the mitral regurgitation murmur; of 88 such patients in the 4-week program, 40 (46%) lost the murmur (P < 0.05). Our 12-year prospective and controlled study thus revealed that patients on 4-weekly prophylaxis were still at significant risk of rheumatic recurrence with less favorable long-term prognosis. Based on the results of this 12-year study, we recommend, therefore, 3-weekly injections of 1.2 × 10⁶ units of benzathine penicillin G for both chidren and adults with a recent attack of rheumatic fever with carditis. The benzathine penicillin G may be given every 4 weeks in relatively low-risk patients, such as those who had no carditis in the initial attack, who have already lost the murmur, or in whom more than 5 years have passed since the last attack of rheumatic fever.