All people with acute rheumatic fever or rheumatic heart disease should continue secondary prophylaxis for a minimum of 10 years after the last episode of ARF or until the age of 21 years (whichever is longer). Those with moderate or severe rheumatic heart disease should continue secondary prophylaxis up to the age of 35–40 years.
Secondary prophylaxis with benzathine penicillin G (BPG) is recommended for all people with a history of ARF or RHD. Four-weekly BPG is currently the treatment of choice, except in patients considered to be at high-risk, for whom 3-weekly administration is recommended. The benefits of 3-weekly BPG injections are offset by the difficulties of achieving good adherence, even to the standard 4-weekly regimen. Data from the Northern Territory show that few, if any, recurrences occurred among people who fully adhered to a 4-weekly benzathine penicillin G regimen.
Alternatives to benzathine penicillin G are available, although they are less effective and require careful monitoring.
The appropriate duration of secondary prophylaxis is determined by a number of factors including age, time since the last episode of ARF, ongoing risk of streptococcal infections and potential harm from recurrent acute rheumatic fever.
Infective endocarditis is a dangerous complication of rheumatic heart disease and a common adverse event following prosthetic valve replacement in Aboriginal and Torres Strait Islander Australians. People with established rheumatic heart disease or prosthetic valves should receive antibiotic prophylaxis prior to procedures expected to produce bacteraemia (e.g. dental procedures, surgical procedures where infection is present).