Table 1

Summary of recommendations for secondary prophylaxis of acute rheumatic fever

First-line treatmentSecond-line treatmentPenicillin allergicDuration
Australia94BPG 1.2 MU ≥20 kg
BPG 0.6 MU <20 kg
3–4 weekly
Pen V 250 mg BDErythromycin 250 mg BDMin 10 years or until age 21
Mod/severe RHD: up to 35–40 years or longer
India95BPG 1.2 MU ≥27 kg
BPG 0.6 MU <27 kg
3 weekly
Pen V
Child 250 mg QID
Adult 500 mg TID
Erythromycin 20 mg/kg/dose max 500 mg BDNo carditis: min 5 years or age 18
Mild/moderate and healed carditis: min 10 years or age 25
Severe RHD including previous intervention: age 40 or lifelong
New Zealand96BPG 1.2 MU ≥30 kg
BPG 0.6 MU <30 kg
3–4 weekly
Pen V 250 mg <20 kg
500 mg ≥20 kg
2–3/day
Erythromycin 40 mg/kg per day
max 1000 mg/day in 2–3 divided doses
Possible ARF: 5 years
No/mild carditis: min 10 years or until age 21, 5 years if age >21
Mod/severe carditis: min 10 years or until age 30, longer in high-risk groups
South Africa97BPG 1.7 MU >30 kg
BPG 0.6–0.9 MU <30 kg
2–4 weekly
Pen V 250 mg BD >30 kg
125 mg BD <30 kg
Erythromycin 250 mg BDUp to age 21
Confirmed RHD: up to age 35
USA98BPG 1.2 MU >27 kg
BPG 0.6 MU ≤27 kg
Pen V 250 mg BDSulfadiazine 1 g OD >27 kg
0.5 g OD ≤27 kg
or macrolide or azalide
No carditis: min 5 years or age 21
Carditis but no residual RHD: 10 years or age 21
Carditis and RHD: 10 years or age 40, but lifelong may be needed
WHO99BPG 1.2 MU ≥30 kg
BPG 0.6 MU <30 kg
3–4 weekly
Pen V 250 mg BDSulfonamide, eg, sulfadiazine 1 g OD ≥30 kg
500 mg OD <30 kg or erythromycin 250 mg BD
No carditis: min 5 years or age 18
Carditis: min 10 years or age 25
More severe: lifetime
  • ARF, acute rheumatic fever; BD, twice daily; BPG, benzathine penicillin G; min, minimum; MU, million units; OD, once daily; Pen V, phenoxymethylpenicillin (Penicillin V); QID, four times daily; RHD, rheumatic heart disease; TID, three times daily.