reflective diary 1

trying to enchance my feeling ... huhu ,


    my reflective diary DAY 1 ,


i have one pt , known as KHIDIR not his real name ... a young boy , admitted to ward because of oedema at both of his eyes during the morning ....


premorbid ?! had nephrotic syndromme ... then what is nephrotic syndromme ?! here are some details for it ... 


NEPHROTIC SYNDROME 


a group of symptoms that include protein in the urine , low blood protein levels, high cholestrol levels, high triglyceride levels, and swelling.


cause , incidence, and risk factors ...


N.S is caused by different disorders that damage the kidneys and this leads to the release of too much protein in the urine.

The most common cause in children is minimal change disease. Membranous glomerulonephritis is the most common cause in adults.

This condition can also occur from:

• Cancer
• Diseases such as diabetes, systemic lupus erythematosus, multiple myeloma, and amyloidosis
• Genetic disorders
• Immune disorders
• Infections (such as strep throat, hepatitis, or mononucleosis)
• Use of certain drugs

It can occur with kidney disorders such as:

• Focal and segmental glomerulosclerosis
• Glomerulonephritis
• Mesangiocapillary glomerulonephritis

Nephrotic syndrome can affect all age groups. In children, it is most common between ages 2 and 6. This disorder occurs slightly more often in males than females.

symptoms ....

edema (swelling) ... at 

: face and around the eyes (facial swelling)

: arm and legs, esp in the feet and ankles

: belly area ( swollen abdomen )

other sympton may include ...

- foamy appearance of the urine 

poor appetite

wt gain ( unintentional) fr fluid retention 

Signs and tests


The doctor will perform a physical exam. Laboratory tests will be done to see how well the kidneys are working. They include:


Albumin blood test


Blood chemistry tests such as basic metabolic panel or comprehensive metabolic panel


Blood urea nitrogen (BUN)


Creatinine - blood test

• Creatinine clearance - urine test
• Urinalysis

Fats are often also present in the urine. Blood cholesterol and triglyceride levelsmay be high.

A kidney biopsy may be needed to find the cause of the disorder.

Tests to rule out various causes may include the following:

• Antinuclear antibody
• Cryoglobulins
• Complement levels
• Glucose tolerance test
• Hepatitis B and C antibodies
• HIV test



Rheumatoid factor


Serum protein electrophoresis (SPEP)


Syphilis serology


Urine protein electrophoresis (UPEP)


This disease may also change the results of the following tests:


Vitamin D level


Serum iron


Urinary casts

• 
  
  
  

  Treatment

  The goals of treatment are to relieve symptoms, prevent complications, and delay kidney damage. To control nephrotic syndrome, you must treat the disorder that is causing it. You may need treatment for life.

  Treatments:

  • Keep blood pressure at or below 130/80 mmHg to delay kidney damage. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the medicines most often used. ACE inhibitors may also help decrease the amount of protein lost in the urine.
  • You may take corticosteroids and other drugs that suppress or quiet the immune system.
  • Treat high cholesterol to reduce the risk of heart and blood vessel problems. A low-fat, low-cholesterol diet is usually not very helpful for people with nephrotic syndrome. Medications to reduce cholesterol and triglycerides (usually statins) may be needed.
  • A low-salt diet may help with swelling in the hands and legs. Water pills (diuretics) may also help with this problem.
  • Low-protein diets may be helpful. Your health care provider may suggest eating a moderate-protein diet (1 gram of protein per kilogram of body weight per day).
  • You may need vitamin D supplements if nephrotic syndrome is long-term and not responding to treatment.
  • Blood thinners may be needed to treat or prevent blood clots.

  Expectations (prognosis)

  The outcome varies. The condition may be acute and short-term or chronic and not respond to treatment. The complications that occur can also affect the outcome.

  Some people may eventually need dialysis and a kidney transplant.

  
  

  
  

  complications :

  : acute renal (kidney )failure

  :atherosclerosis and related heart diseases

  :chronic kidney disease

  :fluid overload, congestive heart failure, pulmonary edema

  :infections , including pneumococcal pneumonia

  :malnutrition

  :renal vein thrombosis

  
  

  sources ... 

  
  

  
  

  and the new diagnosis for this kid after admission is rheumatic carditis .. . which is concern me more to know bout this disease .. after reviewing much articles , its kinda interesting disease ... this is apart of my reading ... 

  
  

  Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults in the United States.

  Acute rheumatic fever and rheumatic heart disease are thought to result from an autoimmune response, but the exact pathogenesis remains unclear. Although rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States, incidence of this disease has decreased in developed countries, and the mortality rate has dropped to just above 0% since the 1960s. Worldwide, rheumatic heart disease remains a major health problem. Chronic rheumatic heart disease is estimated to occur in 5-30 million children and young adults; 90,000 individuals die from this disease each year. The mortality rate from this disease remains 1-10%. A comprehensive resource provided by the World Health Organization (WHO) addresses the diagnosis and treatment.^[1]

  
  

  Rheumatic fever develops in some children and adolescents following pharyngitis with group A beta-hemolytic Streptococcus (ie, Streptococcus pyogenes). The organisms attach to the epithelial cells of the upper respiratory tract and produce a battery of enzymes allowing them to damage and invade human tissues. After an incubation period of 2-4 days, the invading organisms elicit an acute inflammatory response with 3-5 days of sore throat, fever, malaise, headache, and an elevated leukocyte count.

  In 0.3-3% of cases, infection leads to rheumatic fever several weeks after the sore throat has resolved. Only infections of the pharynx initiate or reactivate rheumatic fever. The organism spreads by direct contact with oral or respiratory secretions, and spread is enhanced by crowded living conditions. Patients remain infected for weeks after symptomatic resolution of pharyngitis and may serve as a reservoir for infecting others. Penicillin treatment shortens the clinical course of streptococcal pharyngitis and, more importantly, is effective in decreasing the incidence of major sequelae.

  Group A Streptococcus is a gram-positive coccus that frequently colonizes the skin and oropharynx. This organism may cause suppurative disease, such as pharyngitis, impetigo, cellulitis, myositis, pneumonia, and puerperal sepsis. It also may be associated with nonsuppurative disease, such as rheumatic fever and acute poststreptococcal glomerulonephritis. Group A streptococci elaborate the cytolytic toxins streptolysins S and O. Of these, streptolysin O induces persistently high antibody titers that provide a useful marker of group A streptococcal infection and its nonsuppurative complications.

  Group A Streptococcus, as identified using the Lancefield classification, has a group A carbohydrate antigen in the cell wall that is composed of a branched polymer of L- rhamnose and N- acetyl-D-glucosamine in a 2:1 ratio.

  Group A streptococci may be subserotyped by surface proteins on the cell wall of the organism. The presence of the M protein is the most important virulence factor for group A streptococcal infection in humans.

  More than 120 M protein serotypes or M protein genotypes have been identified^[2] , some of which have a long terminal antigenic domain (ie, epitopes) similar to antigens in various components of the human heart.

  Rheumatogenic strains are often encapsulated mucoid strains, rich in M proteins, and resistant to phagocytosis. These strains are strongly immunogenic, and anti-M antibodies against the streptococcal infection may cross-react with components of heart tissue (ie, sarcolemmal membranes, valve glycoproteins). Currently, emm typing is felt to be more discriminating than M typing.^[2]

  Acute rheumatic heart disease often produces a pancarditis characterized by endocarditis, myocarditis, and pericarditis. Endocarditis is manifested as valve insufficiency. The mitral valve is most commonly and severely affected (65-70% of patients), and the aortic valve is second in frequency (25%). The tricuspid valve is deformed in only 10% of patients and is almost always associated with mitral and aortic lesions. The pulmonary valve is rarely affected. Severe valve insufficiency during the acute phase may result in congestive heart failure and even death (1% of patients). Whether myocardial dysfunction during acute rheumatic fever is primarily related to myocarditis or is secondary to congestive heart failure from severe valve insufficiency is not known. Pericarditis, when present, rarely affects cardiac function or results in constrictive pericarditis.

  Chronic manifestations due to residual and progressive valve deformity occur in 9-39% of adults with previous rheumatic heart disease. Fusion of the valve apparatus resulting in stenosis or a combination of stenosis and insufficiency develops 2-10 years after an episode of acute rheumatic fever, and recurrent episodes may cause progressive damage to the valves. Fusion occurs at the level of the valve commissures, cusps, chordal attachments, or any combination of these. Rheumatic heart disease is responsible for 99% of mitral valve stenosis in adults in the United States. Associated atrial fibrillation or left atrial thrombus formation from chronic mitral valve involvement and atrial enlargement may be observed.

  
  

  Frequency

  United States

  At this time, rheumatic fever is uncommon among children in the United States. Incidence of rheumatic fever and rheumatic heart disease has decreased in the United States and other industrialized countries in the past 80 years. Prevalence of rheumatic heart disease in the United States now is less than 0.05 per 1000 population, with rare regional outbreaks reported in Tennessee in the 1960s and in Utah, Ohio, and Pennsylvania in the 1980s. In the early 1900s, incidence was reportedly 5-10 cases per 1000 population. Decreased incidence of rheumatic fever has been attributed to the introduction of penicillin or a change in the virulence of the Streptococcus.

  International

  In contrast to trends in the United States, the incidence of rheumatic fever and rheumatic heart disease has not decreased in developing countries. Retrospective studies reveal developing countries to have the highest figures for cardiac involvement and recurrence rates of rheumatic fever. Estimations worldwide are that at least 15.6 million children and young adults have rheumatic heart disease, and 233,000 patients die from this disease each year.^[3]

  A study of school children in Cambodia and Mozambique with rheumatic fever showed that rheumatic heart disease prevalence when echocardiography is used for screening is 10 fold greater compared with the prevalence when clinical examination alone is performed.^[4]

  Mortality/Morbidity

  Rheumatic heart disease is the major cause of morbidity from rheumatic fever and the major cause of mitral insufficiency and stenosis in the United States and the world. Variables that correlate with severity of valve disease include the number of previous attacks of rheumatic fever, the length of time between the onset of disease and start of therapy, and sex. (The disease is more severe in females than in males.) Insufficiency from acute rheumatic valve disease resolves in 60-80% of patients who adhere to antibiotic prophylaxis.

  Race

  Native Hawaiian and Maori (both of Polynesian descent) have a higher incidence of rheumatic fever (13.4 per 100,000 hospitalized children per year), even with antibiotic prophylaxis of streptococcal pharyngitis. Otherwise, race (when controlled for socioeconomic variables) has not been documented to influence disease incidence.

  Sex

  Rheumatic fever occurs in equal numbers in males and females, but the prognosis is worse for females than for males.

  Age

  Rheumatic fever is principally a disease of childhood, with a median age of 10 years, although it also occurs in adults (20% of cases).

  
  

  A diagnosis of rheumatic heart disease is made after confirming antecedent rheumatic fever. The modified Jones criteria (revised in 1992) provide guidelines for the diagnosis of rheumatic fever.^[5]

  The Jones criteria require the presence of 2 major or 1 major and 2 minor criteria for the diagnosis of rheumatic fever. The major diagnostic criteria include carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum. The minor diagnostic criteria include fever, arthralgia, prolonged PR interval on ECG, elevated acute phase reactants (increased erythrocyte sedimentation rate [ESR]), presence of C-reactive protein, and leukocytosis.

  Additional evidence of previous group A streptococcal pharyngitis is required to diagnose rheumatic fever. One of the following must be present:

  • Positive throat culture or rapid streptococcal antigen test result
  • Elevated or rising streptococcal antibody titer
  • History of previous rheumatic fever or rheumatic heart disease

  These criteria are not absolute; the diagnosis of rheumatic fever can be made in a patient with chorea alone if the patient has had documented group A streptococcal pharyngitis.

  After a diagnosis of rheumatic fever is made, symptoms consistent with heart failure, such as difficulty breathing, exercise intolerance, and a rapid heart rate out of proportion to fever, may be indications of carditis and rheumatic heart disease.

  Rheumatic fever is thought to result from an inflammatory autoimmune response. Rheumatic fever only develops in children and adolescents following group A beta-hemolytic streptococcal pharyngitis, and only streptococcal infections of the pharynx initiate or reactivate rheumatic fever.

  Genetic studies show strong correlation between progression to rheumatic heart disease and human leukocyte antigen (HLA)-DR class II alleles and the inflammatory protein-encoding genes MBL2 and TNFA.^[3] Furthermore, both clones of heart tissue–infiltrating T cells and antibodies have been found to be cross-reactive with beta-hemolytic streptococcus. Interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, and interleukin (IL)-10-(+) cells are consistently predominant in valvular tissue, whereas IL-4 regulatory cytokine expression is consistently low.

  The proposed pathophysiology for development of rheumatic heart disease is as follows: Cross-reactive antibodies bind to cardiac tissue facilitating infiltration of streptococcal-primed CD4+ T cells, which then trigger an autoimmune reaction releasing inflammatory cytokines (including TNF-alpha and IFN-gamma). Because few IL-4–producing cells are present in valvular tissue, inflammation persists, leading to valvular lesions.

  
  

  Laboratory Studies

  Throat culture

  Throat culture findings for group A beta hemolytic Streptococcus are usually negative by the time symptoms of rheumatic fever or rheumatic heart disease appear. Attempts should be made to isolate the organism before the initiation of antibiotic therapy to help confirm a diagnosis of streptococcal pharyngitis and to allow typing of the organism if it is isolated successfully.

  Rapid antigen detection test

  This test allows rapid detection of group A streptococcal antigen and allows the diagnosis of streptococcal pharyngitis and the initiation of antibiotic therapy while the patient is still in the physician's office. Because the rapid antigen detection test has a specificity of greater than 95% but a sensitivity of only 60-90%, a throat culture should be obtained in conjunction with this test.

  Antistreptococcal antibodies

  The clinical features of rheumatic fever begin at the time antistreptococcal antibody levels are at their peak. Thus, antistreptococcal antibody testing is useful for confirming previous group A streptococcal infection. The elevated level of antistreptococcal antibodies is useful, particularly in patients that present with chorea as the only diagnostic criterion. Sensitivity for recent infections can be improved by testing for several antibodies. Antibody titers should be checked at 2-week intervals in order to detect a rising titer.

  The most common extracellular antistreptococcal antibodies tested include antistreptolysin O (ASO), antideoxyribonuclease (DNAse) B, antihyaluronidase, antistreptokinase, antistreptococcal esterase, and anti-DNA. Antibody tests for cellular components of group A streptococcal antigens include antistreptococcal polysaccharide, antiteichoic acid antibody, and anti–M protein antibody.

  In general, the ratio of antibodies to extracellular streptococcal antigens rises during the first month after infection and then plateaus for 3-6 months before returning to normal levels after 6-12 months. When the ASO titer peaks (2-3 wk after the onset of rheumatic fever), the sensitivity of this test is 80-85%. The anti-DNAse B has a slightly higher sensitivity (90%) for detecting rheumatic fever or acute glomerulonephritis. Antihyaluronidase results are frequently abnormal in rheumatic fever patients with a normal level of ASO titer and may rise earlier and persist longer than elevated ASO titers during rheumatic fever.

  Acute phase reactants

  The C-reactive protein and erythrocyte sedimentation rate are elevated in rheumatic fever due to the inflammatory nature of the disease. Both tests have a high sensitivity but low specificity for rheumatic fever. They may be used to monitor the resolution of inflammation, detect relapse when weaning aspirin, or identify the recurrence of disease.

  Heart reactive antibodies

  Tropomyosin is elevated in acute rheumatic fever.

  Rapid detection test for D8/17

  This immunofluorescence technique for identifying the B cell marker D8/17 is positive in 90% of patients with rheumatic fever. It may be useful for identifying patients who are at risk for developing rheumatic fever.

  
  

  
  

  Imaging Studies

  Chest roentgenography

  Cardiomegaly, pulmonary congestion, and other findings consistent with heart failure may be seen on chest radiography. When the patient has fever and respiratory distress, chest radiography helps differentiate heart failure from rheumatic pneumonia.

  Doppler-echocardiogram

  In acute rheumatic heart disease, Doppler-echocardiography identifies and quantitates valve insufficiency and ventricular dysfunction. Studies in Cambodia and Mozambique demonstrated a 10-fold increase in the prevalence of rheumatic heart disease when echocardiography is used for clinical screening compared with strictly clinical findings.^[4]

  With mild carditis, Doppler evidence of mitral regurgitation may be present during the acute phase of disease but resolves in weeks to months. In contrast, patients with moderate-to-severe carditis have persistent mitral and/or aortic regurgitation.

  The most important echocardiographic features of mitral regurgitation from acute rheumatic valvulitis are annular dilatation, elongation of the chordae to the anterior leaflet, and a posterolaterally directed mitral regurgitation jet.

  During acute rheumatic fever, the left ventricle is frequently dilated in association with a normal or increased fractional shortening. Thus, some cardiologists believe that valve insufficiency (from endocarditis), rather than myocardial dysfunction (from myocarditis), is the dominant cause of heart failure in acute rheumatic fever.

  In chronic rheumatic heart disease, echocardiography may be used to track the progression of valve stenosis and may help determine the time for surgical intervention. The leaflets of affected valves become diffusely thickened, with fusion of the commissures and chordae tendineae. Increased echodensity of the mitral valve may signify calcification.

  The image below depicts the typical systolic mitral insufficiency jet observed with rheumatic heart disease.

  Parasternal long-axis view demonstrating the typical systolic mitral insufficiency jet observed with rheumatic heart disease (blue jet extending from the left ventricle into the left atrium). The jet is typically directed to the lateral and posterior wall. (LV=left ventricle; LA=left atrium; Ao=aorta; RV=right ventricle).
  

  The image below depicts the typical diastolic aortic insufficiency jet observed with rheumatic heart disease.

  Parasternal long-axis view demonstrating the typical diastolic aortic insufficiency jet observed with rheumatic heart disease (red jet extending from the aorta into the left ventricle). (LV=left ventricle; LA=left atrium; Ao=aorta; RV=right ventricle).
  

  Heart catheterization

  In acute rheumatic heart disease, this procedure is not indicated. With chronic disease, heart catheterization has been performed to evaluate mitral and aortic valve disease and to balloon stenotic mitral valves.

  Postcatheterization precautions include hemorrhage, pain, nausea and vomiting, and arterial or venous obstruction from thrombosis or spasm.Complications may include mitral insufficiency after balloon dilation of the mitral valve, tachyarrhythmias, bradyarrhythmias, and vascular occlusion.

  
  

  Other Tests

  On ECG, sinus tachycardia most frequently accompanies acute rheumatic heart disease. Alternatively, some children develop sinus bradycardia from increased vagal tone. No correlation between bradycardia and the severity of the carditis is noted.

  First-degree atrioventricular (AV) block (prolongation of the PR interval) is observed in some patients with rheumatic heart disease. This abnormality may be related to localized myocardial inflammation involving the AV node or to vasculitis involving the AV nodal artery. First-degree AV block is a nonspecific finding and should not be used as a criterion for the diagnosis of rheumatic heart disease. Its presence does not correlate with the development of chronic rheumatic heart disease.

  Second-degree (intermittent) and third-degree (complete) AV block with progression to ventricular standstill have been described. Heart block in the setting of rheumatic fever, however, typically resolves with the rest of the disease process.

  When acute rheumatic fever is associated with pericarditis, ST segment elevation may be present and is marked most in lead II, III, aVF, and V₄ -V₆.

  Patients with rheumatic heart disease also may develop atrial flutter, multifocal atrial tachycardia, or atrial fibrillation from chronic mitral valve disease and atrial dilation.

  
  

  Histologic Findings

  Pathologic examination of the insufficient valves may reveal verrucous lesions at the line of closure.

  Aschoff bodies (perivascular foci of eosinophilic collagen surrounded by lymphocytes, plasma cells, and macrophages) are found in the pericardium, perivascular regions of the myocardium, and endocardium. The Aschoff bodies assume a granulomatous appearance with a central fibrinoid focus and eventually are replaced by nodules of scar tissue.

  Anitschkow cells are plump macrophages within Aschoff bodies.

  In the pericardium, fibrinous and serofibrinous exudates may produce an appearance of "bread and butter" pericarditis.

  
  

  Medical Care

  Medical therapy in rheumatic heart disease includes attempts to prevent rheumatic fever (and thus rheumatic heart disease). In patients who develop rheumatic heart disease, therapy is directed toward eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure. Following the resolution of the acute episode, subsequent therapy is directed towards preventing recurrent rheumatic heart disease in children and monitoring for the complications and sequelae of chronic rheumatic heart disease in adults.

  Prevention of rheumatic fever in patients with group A beta hemolytic streptococci (GABHS) pharyngitis

  For patients with GABHS pharyngitis, a meta-analysis supports a protective effect against rheumatic fever when penicillin is used following the diagnosis.^[5]

  Oral (PO) penicillin V remains the drug of choice for treatment of GABHS pharyngitis, but ampicillin and amoxicillin are equally effective.

  When PO penicillin is not feasible or dependable, a single dose of intramuscular benzathine penicillin G or benzathine/procaine penicillin combination is therapeutic.

  For patients who are allergic to penicillin, administer erythromycin or a first-generation cephalosporin. Other options include clarithromycin for 10 days, azithromycin for 5 days, or a narrow-spectrum (first-generation) cephalosporin for 10 days. As many as 15% of patients who are allergic to penicillin are also allergic to cephalosporins.

  Do not use tetracyclines or sulfonamides to treat GABHS pharyngitis.

  For recurrent group A streptococci (GAS) pharyngitis, a second 10-day course of the same antibiotic may be repeated. Alternate drugs include narrow-spectrum cephalosporins, amoxicillin-clavulanate, dicloxacillin, erythromycin, or other macrolides.

  Control measures for patients with GABHS pharyngitis are as follows:

  • Hospitalized patients: Place hospitalized patients with GABHS pharyngitis of pneumonia on droplet precautions, as well as standard precautions, until 24 hours after initiation of appropriate antibiotics.
  • Exposed persons: People in contact with patients having documented cases of streptococcal infection first should undergo appropriate laboratory testing if they have clinical evidence of GABHS infection and should undergo antibiotic therapy if infected.
  • School and childcare centers: Children with GABHS infection should not attend school or childcare centers for the first 24 hours after initiating antimicrobial therapy.

  GABHS carriage is difficult to eradicate with conventional penicillin therapy. Thus, PO clindamycin (20 mg/kg/d PO in 3 divided doses for 10 days) is recommended.

  In general, antimicrobial therapy is not indicated for pharyngeal carriers of GABHS. Exceptions include the following:

  • Outbreaks of rheumatic fever or poststreptococcal glomerulonephritis
  • Family history of rheumatic fever
  • During outbreaks of GAS pharyngitis in a closed community
  • When tonsillectomy is considered for chronic GABHS carriage
  • When multiple episodes of documented GABHS pharyngitis occur within a family despite appropriate therapy
  • Following GAS toxic shock syndrome or necrotizing fasciitis in a household contact

  Treatment for patients with rheumatic fever and rheumatic heart disease

  Therapy is directed towards eliminating the GABHS pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment of congestive heart failure.

  Treat residual GABHS pharyngitis as outlined above, if still present.

  Treatment of the acute inflammatory manifestations of acute rheumatic fever consists of salicylates and steroids. Aspirin in anti-inflammatory doses effectively reduces all manifestations of the disease except chorea, and the response is typically dramatic.

  If rapid improvement is not observed after 24-36 hours of therapy, question the diagnosis of rheumatic fever.

  Attempt to obtain aspirin blood levels from 20-25 mg/dL, but stable levels may be difficult to achieve during the inflammatory phase because of variable GI absorption of the drug. Maintain aspirin at anti-inflammatory doses until the signs and symptoms of acute rheumatic fever are resolved or residing (6-8 wk) and the acute phase reactants (APRs) have returned to normal.

  Anti-inflammatory doses of aspirin may be associated with abnormal liver function tests and GI toxicity, and adjusting the aspirin dosage may be necessary.

  When discontinuing therapy, withdraw aspirin gradually over weeks while monitoring the APRs for evidence of rebound. Chorea is most frequently self-limited but may be alleviated or partially controlled with phenobarbital or diazepam.

  If moderate to severe carditis is present as indicated by cardiomegaly, third-degree heart block or congestive heart failure, substitute PO prednisone for salicylate therapy. Continue prednisone for 2-6 weeks depending on the severity of the carditis, and taper prednisone during the final week(s) of therapy. Weaning prednisone therapy after a shorter period (2-4 weeks) while initiating and maintaining salicylates for several weeks can minimize adverse effects of the steroids while preventing rebound of the carditis.

  Include digoxin and diuretics, afterload reduction, supplemental oxygen, bed rest, and sodium and fluid restriction as additional treatment for patients with acute rheumatic fever and heart failure. The diuretics most commonly used in conjunction with digoxin for children with heart failure include furosemide and spironolactone. Initiate digoxin only after checking electrolytes and correcting hypokalemia.

  The total digitalizing dose is 20-30 mcg/kg PO, with 50% of the dose administered initially, followed by 25% of the dose 12 hours and 24 hours after the initial dose. Maintenance doses typically are 8-10 mcg/kg/d PO in 2 divided doses. For older children and adults, the total loading dose is 1.25-1.5 mg PO, and the maintenance dose is 0.25-0.5 mg PO every day. Therapeutic digoxin levels are present at trough levels of 1.5-2 ng/mL.

  Afterload reduction (ie, using ACE inhibitor captopril) may be effective in improving cardiac output, particularly in the presence of mitral and aortic insufficiency. Start these agents judiciously. Use a small, initial test dose (some patients have an abnormally large response to these agents), and administer only after correcting hypovolemia.

  When heart failure persists or progresses during an episode of acute rheumatic fever in spite of aggressive medical therapy, surgery is indicated and may be life-saving for severe mitral and/or aortic insufficiency.

  Treatment for patients following rheumatic heart disease (RHD)

  Preventive and prophylactic therapy is indicated after rheumatic fever and acute rheumatic heart disease to prevent further damage to valves.

  Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis (prevention of recurrent rheumatic fever and rheumatic heart disease).

  An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4 weeks is the recommended regimen for secondary prophylaxis for most US patients. Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in patients with residual carditis, and in high-risk patients.

  Although PO penicillin prophylaxis is also effective, data from the World Health Organization indicate that the recurrence risk of GABHS pharyngitis is lower when penicillin is administered parentally.

  The duration of antibiotic prophylaxis is controversial. Continue antibiotic prophylaxis indefinitely for patients at high risk (eg, health care workers, teachers, daycare workers) for recurrent GABHS infection. Ideally, one could argue for continuing prophylaxis indefinitely, because recurrent GABHS infection and rheumatic fever can occur at any age; however, the American Heart Association currently recommends that patients with rheumatic fever without carditis receive prophylactic antibiotics for 5 years or until aged 21 years, whichever is longer.^[7] Patients with rheumatic fever and carditis but no valve disease should receive prophylactic antibiotics for 10 years or well into adulthood, whichever is longer. Finally, patients with rheumatic fever with carditis and valve disease should receive antibiotics for at least 10 years or until age 40 years.

  Patients with rheumatic heart disease and valve damage require a single dose of antibiotics 1 hour before surgical and dental procedures to help prevent bacterial endocarditis. Patients who had rheumatic fever without valve damage do not need endocarditis prophylaxis. Do not use penicillin, ampicillin, or amoxicillin for endocarditis prophylaxis in patients already receiving penicillin for secondary rheumatic fever prophylaxis (relative resistance of PO streptococci to penicillin and aminopenicillins). Alternate drugs recommended by the American Heart Association for these patients include PO clindamycin (20 mg/kg in children, 600 mg in adults) and PO azithromycin or clarithromycin (15 mg/kg in children, 500 mg in adults). The guidelines for endocarditis prophylaxis in patients with valve damage from rheumatic heart disease have changed. Antibiotic prophylaxis is no longer recommended.^[7]

  A recent study investigated the difference in clinical manifestations and outcomes between first episode and recurrent rheumatic fever.^[8] The study concluded that subclinical carditis occurred only in patients experiencing the first episode, and that all deaths occurred in patients with recurrent rheumatic fever, emphasizing the need for secondary prophylaxis.

  
  

  Medication Summary

  Medical therapy is directed at eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure. The treatment and prevention of group A streptococcal pharyngitis outlined here is based on the current recommendations of the Committee on Infectious Disease (American Academy of Pediatrics). See the eMedicine articlePharyngitis.

  Penicillin V is the drug of choice for treatment of group A streptococcal pharyngitis. Ampicillin or amoxicillin may be used instead of penicillin V but have no microbiologic advantage. Tetracyclines and sulfonamides should not be used to treat group A streptococcal pharyngitis. For recurrent group A streptococcal pharyngitis, a second 10-day course of the same antibiotic can be repeated. Alternate drugs include narrow-spectrum cephalosporins, amoxicillin-clavulanate, dicloxacillin, erythromycin, or other macrolides for 10 d. As many as 15% of patients allergic to penicillin are also allergic to cephalosporins.

  
  

  Antibiotics

  Class Summary

  Antibiotics are used for the initial treatment of group A streptococcal pharyngitis to prevent the first attack of rheumatic fever (primary prophylaxis), for recurrent streptococcal pharyngitis, and for continuous therapy to prevent recurrent rheumatic fever and rheumatic heart disease (secondary prophylaxis).

  
  

  http://reference.medscape.com/drug/pen-vee-k-penicillin-v-penicillin-vk-342483#1

  Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K)

  
  

  Pediatric Dosing & Uses

  Dosing Forms & Strengths

  oral solution

  • 125mg
  • 250mg

  tablet

  • 250mg
  • 500mg

  Pneumococcal Systemic Infections

  < 12 years old

  • 25-50 mg/kg/day q6-8hr PO
  • No more than 3 g/day

  >12 years old

  • 125-500 mg q6-8hr PO

  Primary Prevention of Rheumatic Fever

  Children: 250 mg BID-TID PO x 10 days

  Adolescents: 500 mg BID-TID PO x 10 days

  Recurrent Rheumatic Fever Prophylaxis

  Children: 250 mg BID PO

  Administration

  Take on empty stomach

  
  

  Contraindicated (0)

  Serious - Use Alternative (10)

  • bcg vaccine live
  • demeclocycline
  • doxycycline
  • lymecycline
  • minocycline
  • mycophenolate
  • oxytetracycline
  • probenecid
  • tetracycline
  • typhoid vaccine live

  Significant - Monitor Closely (113)

  • aceclofenac
  • acemetacin
  • acyclovir
  • amiloride
  • ascorbic acid
  • aspirin
  • aspirin rectal
  • balsalazide
  • bendroflumethiazide
  • bromfenac
  • bupropion
  • cefaclor
  • cefadroxil
  • cefamandole
  • cefazolin
  • cefdinir
  • cefditoren
  • cefepime
  • cefixime
  • cefmetazole
  • cefoperazone
  • cefotaxime
  • cefotetan
  • cefoxitin
  • cefpirome
  • cefpodoxime
  • cefprozil
  • ceftazidime
  • ceftibuten
  • ceftizoxime
  • ceftobiprole
  • ceftriaxone
  • cefuroxime
  • celecoxib
  • cephalexin
  • cephalothin
  • cephradine
  • chlorothiazide
  • chlorotrianisene
  • chlorpropamide
  • chlorthalidone
  • choline magnesium trisalicylate
  • clofibrate
  • conjugated estrogens
  • cyclopenthiazide
  • diclofenac
  • dienestrol
  • dienogest/estradiol valerate
  • diethylstilbestrol
  • diflunisal
  • digoxin
  • drospirenone
  • eltrombopag
  • estradiol
  • estrogens conjugated synthetic
  • estrogens esterified
  • estrone
  • estropipate
  • ethinylestradiol
  • etodolac
  • etoricoxib
  • fenbufen
  • fenoprofen
  • floctafenine
  • flurbiprofen
  • ganciclovir
  • hydrochlorothiazide
  • hydroflumethiazide
  • ibuprofen
  • indapamide
  • indomethacin
  • ketoprofen
  • ketorolac
  • ketorolac intranasal
  • loracarbef
  • lornoxicam
  • meclofenamate
  • mefenamic acid
  • meloxicam
  • mesalamine
  • mestranol
  • methotrexate
  • methyclothiazide
  • metolazone
  • nabumetone
  • naproxen
  • neomycin po
  • oxaprozin
  • parecoxib
  • phenylbutazone
  • piroxicam
  • polythiazide
  • potassium acid phosphate
  • potassium chloride
  • potassium citrate
  • rofecoxib
  • rose hips
  • salicylates (non-asa)
  • salsalate
  • sodium phenylacetate
  • spironolactone
  • sulfasalazine
  • sulfinpyrazone
  • sulindac
  • tenoxicam
  • tiaprofenic acid
  • tolfenamic acid
  • tolmetin
  • triamterene
  • trichlormethiazide
  • valdecoxib
  • valganciclovir
  • willow bark

  Minor (16)

  • azithromycin
  • aztreonam
  • balsalazide
  • biotin
  • chloramphenicol
  • clarithromycin
  • colestipol
  • dirithromycin
  • erythromycin base
  • niacin
  • pantothenic acid
  • pyridoxine
  • pyridoxine (antidote)
  • roxithromycin
  • thiamine
  • vitamin k1 (phytonadione)

  Adverse Effects

  >10%

  Diarrhea

  Nausea

  Oral candidiasis

  Vomiting

  <1%

  Seizure

  Anemia

  Interstitial nephritis

  Hypersensitivity

  Anaphylaxis

  Positive Coombs' reaction

  
  

  Contraindications & Cautions

  Contraindications

  Allergy to penicillins, cephalosporins, imipenem

  Cautions

  Caution in renal impairment

  
  

  Pregnancy & Lactation

  Pregnancy Category: B

  Lactation: excreted in breast milk

  
  

  Pharmacology

  Half-Life: 0.5-0.6 hr

  Protein Bound: 80%

  Peak Plasma Time: oral 0.5-1 hr

  Absorption: oral 60-73%

  Distribution: crosses placenta, poor blood brain barrier diffusion

  Metabolism: hepatic

  Elimination: urine

  Mechanism of Action

  Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

  
  

  Patient Education
  penicillin V potassium Oral

  IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

  PENICILLIN V POTASSIUM - ORAL LIQUID

  (pen-ih-SILL-in VEE poh-TASS-ee-um)

  COMMON BRAND NAME(S): Ledercillin VK, Pen-Vee K, Veetids

  USES:
  Penicillin is an antibiotic used to treat and prevent a wide variety of bacterial infections. It works by stopping the growth of bacteria.

  This antibiotic treats only bacterial infections. It will not work for viral infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness.

  HOW TO USE:
  Shake the bottle well before each dose. Carefully measure the dose using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose. This medication may be taken with or without food. However, penicillin is best absorbed when taken on an empty stomach (1 hour before or 2 hours after meals).

  The dosage is based on your medical condition and response to therapy. In children, the dosage is also based on weight.

  Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, take this drug at evenly spaced intervals.

  Continue to take this medication until the full-prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may allow bacteria to continue to grow, which may result in a relapse of the infection.

  Inform your doctor if your condition persists or worsens.

  SIDE EFFECTS:
  Upset stomach, nausea, vomiting, diarrhea, and mouth sores may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

  Although uncommon, you may develop a black, "hairy" tongue while taking this medication. This effect is harmless and usually goes away after treatment. Maintain good oral hygiene, and brush your tongue with a soft toothbrush twice a day. Consult your doctor or pharmacist for more information.

  Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

  Tell your doctor immediately if any of these unlikely but serious side effects occur: unusual tiredness, joint/muscle pain.

  Tell your doctor immediately if any of these rare but very serious side effects occur: easy bruising/bleeding.

  This medication may rarely cause a severe intestinal condition (Clostridium difficile-associated diarrhea) due to a type of resistant bacteria. This condition may occur during treatment or weeks to months after treatment has stopped. Do not use anti-diarrhea products or narcotic pain medications if you have any of the following symptoms because these products may make them worse. Tell your doctor immediately if you develop: persistent diarrhea, abdominal or stomach pain/cramping, blood/mucus in your stool.

  Use of this medication for prolonged or repeated periods may result in oral thrush or a new vaginal yeast infection (oral or vaginal fungal infection). Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge or other new symptoms.

  A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching/swelling (especially of the face/tongue/throat), new fever, severe dizziness, trouble breathing.

  This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

  In the US -

  Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

  In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

  PRECAUTIONS:
  Before taking penicillin, tell your doctor or pharmacist if you are allergic to it; or to other antibiotics including penicillin-type medications (e.g., amoxicillin, ampicillin) or cephalosporins (e.g., cephalexin, cefuroxime); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

  Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney problems.

  This medication may contain aspartame. If you have phenylketonuria (PKU) or any other condition that requires you to restrict your intake of aspartame (or phenylalanine), consult your doctor or pharmacist regarding the safe use of this medicine.

  Kidney function declines as you grow older. This medication is removed by the kidneys. Therefore, elderly people may be more sensitive to this drug.

  Kidney function is not fully developed in newborns and young infants. This medication is removed by the kidneys. Therefore, newborns and young infants may be more sensitive to this drug.

  This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.

  This drug passes into breast milk. Consult your doctor before breast-feeding.

  DRUG INTERACTIONS:
  Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

  Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: live bacterial vaccines, methotrexate, tetracyclines, khat, guar gum.

  Before taking penicillin, tell your doctor or pharmacist if you are also taking probenecid. Probenecid slows down the removal of penicillin from your body, resulting in higher levels of this antibiotic in your bloodstream. For certain types of difficult-to-treat infections, your doctor may prescribe these 2 medications together in order to achieve this effect. Consult your doctor or pharmacist for more details.

  Although most antibiotics probably do not affect hormonal birth control such as pills, patch, or ring, some antibiotics may decrease their effectiveness. This could cause pregnancy. Examples include rifamycins such as rifampin or rifabutin. Be sure to ask your doctor or pharmacist if you should use additional reliable birth control methods while using this antibiotic.

  Penicillin may cause false positive results with certain diabetic urine testing products (cupric sulfate-type). This drug may also affect the results of certain lab tests. Make sure laboratory personnel and your doctors know you use this drug.

  This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

  OVERDOSE:
  If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include: severe vomiting, persistent diarrhea.

  NOTES:
  Do not share this medication with others.

  This medication has been prescribed for your current condition only. Do not use it later for another infection unless told to do so by your doctor. A different medication may be necessary in those cases.

  With prolonged treatment, laboratory and/or medical tests (e.g., kidney function, complete blood counts) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

  MISSED DOSE:
  If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

  STORAGE:
  Refrigerate the suspension between 36-46 degrees F (2-8 degrees C). Throw away any unused portion after 14 days since the drug loses potency after that time. Keep all medicines away from children and pets.

  Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

  Information last revised January 2011 Copyright(c) 2011 First DataBank, Inc.

  
  

  Penicillin G benzathine/penicillin G procaine (Bicillin L-A, Wycillin)

  Used when PO administration of penicillin is not feasible or dependable. Discomfort of IM injection may be minimized if the penicillin G is brought to room temperature before injection or if a combination of benzathine penicillin G and procaine penicillin G (Bicillin CR) is used. Initial course of antibiotics given to eradicate the streptococcal infection also serves as the first course of prophylaxis. Benzathine penicillin G IM q4wk is recommended for secondary prevention for most United States patients. The same dosage should be used q3wk in areas where rheumatic fever is endemic, in patients with residual carditis, and in patients with high risk.

  
  

  Pediatric Dosing & Uses

  Dosing Form & Strengths

  penicillin G benzathine/penicillin G procaine

  injectable suspension

  • 600,000units/600,000units/2mL (ie, 1.2 million units/2mL)
  • 900,000units/300,000units/2mL (ie, 1.2 million units/2mL)

  Streptococcal Group A Infections

  Indicated for moderately severe-to-severe infections of upper-respiratory tract, scarlet fever, erysipelas, and skin and soft-tissue infections caused by streptococcal Group A

  Bicillin C-R

  • <14 kg: 600,000 units IM x1
  • 14-27 kg: 900,000-1,200,000 units IM x1
  • 27 kg or more: As adults; 2.4 million units IM x1; divided dosage administration into multiple site; alternatively, administer 1.2 million units IM on day 1, then repeat dose on day 3

  Bicillin C-R 900/300

  • 900 units/300 units IM x1

  Pneumococcal Infections

  NOT for pneumococcal meningitis

  Bicillin C-R: 600,000 units IM; repeat q2-3 days until temperature is normal for 48 hr; other penicillin forms (ie, IV) necessary for severe infection

  Bicillin C-R 900/300: 900 units/300 units IM; repeat q2-3 days until temperature is normal for 48 hr; other penicillin forms (ie, IV) necessary for severe infection

  Renal Impairment

  Not defined in children; see adult recommendations

  
  

  Adverse Effects

  Frequency Not Defined

  Skin rashes including maculopapular eruptions and exfoliative dermatitis

  Urticaria

  Serum-sicknesslike reactions (eg, chills, fever, edema, arthralgia, prostration)

  Jarisch-Herxheimer reaction reported when treating syphilis

  Pseudomembranous colitis

  
  

  Contraindications & Cautions

  Black Box Warnings

  Not for IV use

  Do not inject IV or admix with other IV solutions

  Reports of inadvertent IV administration associated with cardiorespiratory arrest and death

  Prior to administration, carefully read the warnings, adverse reactions, and dosage and administration sections of the labeling

  Contraindications

  Hypersensitivity; serious and occasionally fatal reactions have been reported

  Cautions

  For deep IM administration only; do not administer IV, SC, or IT

  Do not inject near nerve or artery

  Pseudomembranous colitis reported with antibacterial agents, including penicillin G

  Procaine reactions: Immediate toxic reactions to procaine reported, particularly when a large single dose is administered (4.8 million units); reaction manifested by mental disturbances including anxiety, confusion, agitation, depression, weakness, seizures, hallucinations, combativeness, and fear

  Avoid use in neonates; increased risk for sterile abscess development and procaine toxicity

  Severe pneumonia, empyema, bacteremia, pericarditis\is, meningitis, peritonitis, and arthritis of pneumococcal etiology are better treated with penicillin G sodium or potassium during the acute stage

  When high, sustained serum levels are required, penicillin G sodium or potassium, either IM or IV, should be used

  NOT indicated for treatment of venereal diseases, including syphilis, gonorrhea, yaws, bejel, and pinta

  
  

  Pharmacology

  Half-Life: 20-30 minutes after hydrolysis to penicillin G

  Absorption: IM, slow

  Peak Plasma Time: 3 hr

  Peak Plasma Concentration: 1-1.3 units/mL

  Protein Bound: 60%

  Metabolism: ~30% in liver

  Excretion: urine (60-90%)

  Mechanism of Action

  Interferes with cell wall mucopeptide synthesis during active multiplication, resulting in bactericidal activity against susceptible microorganisms

  
  

  IV & IM Information

  IV Administration

  Do not inject near artery or nerve (may result in permanent neurologic damage)

  Neonates, infants, small children: Midlateral aspect of thigh preferable

  Older children and adults: Deep IM injection in upper outer quadrant of buttock

  Because of high concentration of suspended matter, needle may be blocked if injection is not made at slow, steady rate

  Storage

  Store refrigerated at 2-8 degrees C (36-46 degrees F)

  Do not freeze

  
  

  Patient Education
  penicillin G benzathine & proc IM

  IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

  PENICILLIN G BENZATHINE/PENICILLIN G PROCAINE - INJECTION

  (pen-ih-SILL-in G BEN-zuh-theen/pen-ih-SILL-in G PRO-cane)

  COMMON BRAND NAME(S): Bicillin C-R

  WARNING: This medication must not be injected into a vein or mixed with solutions that will be injected into a vein.

  USES:
  This medication is used to treat a wide variety of bacterial infections. This medication is known as a long-acting natural penicillin antibiotic. It works by stopping the growth of bacteria.

  This medication should not be used to treat sexually transmitted diseases (e.g., syphilis, gonorrhea).

  HOW TO USE:
  See also Warning section.

  This medication is given by injection into a large muscle by a health care professional.

  The dosage is based on your medical condition and response to treatment. For children, the dosage is also based on weight.

  Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, if more than one dose is needed, receive this drug at evenly spaced intervals as prescribed by your doctor, and make sure not to miss any doses.

  Continue to receive this medication until the full prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may result in a return of the infection.

  Tell your doctor if your condition persists or worsens.

  SIDE EFFECTS:
  Pain at the injection site, nausea, or vomiting may occur. If these effects persist or worsen, tell your doctor or pharmacist promptly.

  Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

  Tell your doctor right away if you have any serious side effects, including: severe pain/peeling skin at injection site, joint/muscle pain, headache, shortness of breath, dizziness, vision changes, fast/slow/pounding heartbeat, numbness/tingling of arms/legs, pain/redness/swelling of arms/legs, change in skin color near injection site or on arms/legs, uncontrolled movements, inability to move, change in the amount of urine, new signs of infection (e.g., fever, persistent sore throat), easy bruising/bleeding, extreme tiredness, dark/cloudy urine, seizures, mental/mood changes (e.g., depression, agitation).

  Get medical help right away if you have any very serious side effects, including: trouble breathing, chest pain, slurred speech, confusion, fainting.

  This medication may rarely cause a severe intestinal condition (Clostridium difficile-associated diarrhea) due to a type of resistant bacteria. This condition may occur during treatment or weeks to months after treatment has stopped. Do not use anti-diarrhea products or narcotic pain medications if you have any of the following symptoms because these products may make them worse. Tell your doctor right away if you develop: persistent diarrhea, abdominal or stomach pain/cramping, blood/mucus in your stool.

  Use of this medication for prolonged or repeated periods may result in oral thrush or a new vaginal yeast infection. Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge, or other new symptoms.

  A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

  This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

  In the US -

  Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

  In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

  PRECAUTIONS:
  Before using this medication, tell your doctor or pharmacist if you are allergic to it; or to penicillin or cephalosporin antibiotics; or to procaine; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

  Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, asthma.

  Kidney function declines as you grow older. This medication is removed by the kidneys. Therefore, elderly people may be at greater risk for side effects while using this drug.

  Kidney function is not fully developed in newborns/infants. This medication is removed by the kidneys. Therefore, newborns/infants may be at greater risk for side effects while using this drug.

  During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.

  This drug passes into breast milk. Consult your doctor before breast-feeding.

  DRUG INTERACTIONS:
  Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.

  Some products that may interact with this drug include: "blood thinners" (e.g., warfarin), live bacterial vaccines, methotrexate, NSAIDs (e.g., aspirin, indomethacin), probenecid, tetracyclines, "water pills"/diuretics (e.g., furosemide, thiazide diuretics such as hydrochlorothiazide).

  Low-dose aspirin should be continued if prescribed by your doctor for specific medical reasons such as heart attack or stroke prevention (usually at dosages of 81-325 milligrams per day). Ask your doctor or pharmacist for more details.

  Although most antibiotics probably do not affect hormonal birth control such as pills, patch, or ring, some antibiotics may decrease their effectiveness. This could cause pregnancy. Examples include rifamycins such as rifampin or rifabutin. Be sure to ask your doctor or pharmacist if you should use additional reliable birth control methods while using this antibiotic.

  This medication may interfere with certain laboratory tests (including certain urine glucose tests), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

  OVERDOSE:
  If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: seizures, confusion, mental/mood changes (e.g., agitation).

  NOTES:
  Laboratory and/or medical tests (e.g., kidney function, complete blood count) may be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

  MISSED DOSE:
  If you miss a dose, contact your doctor or pharmacist immediately for a new dosing schedule.

  STORAGE:
  Not applicable. This medication is given in a hospital or clinic and will not be stored at home.

  Information last revised September 2011 Copyright(c) 2011 First DataBank, Inc.

  
  

  Erythromycin ethylsuccinate (Ilosone, E.E.S, EryPed)

  http://reference.medscape.com/drug/ees-eryped-erythromycin-ethylsuccinate-999596#1

  
  

  Used to treat patients allergic to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

  
  

  Anti-inflammatory agents

  Class Summary

  The manifestations of acute rheumatic fever (including carditis) typically respond rapidly to therapy with anti-inflammatory agents. Aspirin, in anti-inflammatory doses, is the drug of choice. Prednisone is added when evidence of worsening carditis and heart failure is noted.

  View full drug information

  Aspirin (Anacin, Ascriptin, Bayer Aspirin)

   

  Also called acetylsalicylic acid. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2. Start immediately after the diagnosis of rheumatic fever has been made. Initiation of therapy may mask manifestations of the disease.

  View full drug information

  Prednisone (Deltasone, Orasone)

   

  May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. If moderate to severe carditis is indicated by cardiomegaly, congestive heart failure, or third-degree heart block, 2 mg/kg/d PO should be used in addition to, or in lieu of, salicylate therapy. Prednisone should be continued for 2-4 wk, depending on the severity of the carditis, and tapered during the last week of therapy. Adverse effects can be minimized by discontinuing prednisone therapy after 2 wk and adding or maintaining salicylates for an additional 2-4 wk.

  Previous

  
  

  Angiotensin-converting enzyme (ACE) inhibitors

  Class Summary

  These agents are competitive inhibitors of ACE. They reduce angiotensin II levels and thus decrease aldosterone secretion.

  View full drug information

  Enalapril (Vasotec)

   

  Indicated for chronic aortic and/or mitral regurgitation. Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased plasma renin levels and a reduction in aldosterone secretion. Helps control blood pressure and proteinuria. Decreases pulmonary-to-systemic flow ratio in the catheterization laboratory and increases systemic blood flow in patients with relatively low pulmonary vascular resistance. Has favorable clinical effect when administered over a long period. Helps prevent potassium loss in distal tubules. Body conserves potassium; thus, less oral potassium supplementation needed. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation).

  View full drug information

  Captopril (Capoten)

   

  Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

  Rapidly absorbed, but bioavailability is significantly reduced with food intake. It achieves a peak concentration in 1 h and has a short half-life. The drug is cleared by the kidneys.

  Impaired renal function requires reduction of dosage. Absorbed well PO. Give at least 1 h before meals. If added to water, use within 15 min.

  Can be started at low dose and titrated upward as needed and as patient tolerates.

  
  

  Complications

  Potential complications include heart failure from valve insufficiency (acute rheumatic carditis) or stenosis (chronic rheumatic carditis). Associated cardiac complications include atrial arrhythmias, pulmonary edema, recurrent pulmonary emboli, infective endocarditis, intracardiac thrombus formation, and systemic emboli

  
  

  Prognosis

  Manifestations of acute rheumatic fever resolve over a period of 12 weeks in 80% of patients and may extend as long as 15 weeks in the remaining patients.

  Rheumatic fever was the leading cause of death in people aged 5-20 years in the United States 100 years ago. At that time, the mortality rate was 8-30% from carditis and valvulitis but decreased to a 1-year mortality rate of 4% by the 1930s.

  Following the development of antibiotics, the mortality rate decreased to almost 0% by the 1960s in the United States; however, it has remained 1-10% in developing countries. The development of penicillin has also affected the likelihood of developing chronic valvular disease after an episode of acute rheumatic fever. Before penicillin, 60-70% of patients developed valve disease as compared to 9-39% of patients since penicillin was developed.

  In patients who develop murmurs from valve insufficiency from acute rheumatic fever, numerous factors, including the severity of the initial carditis, the presence or absence of recurrences, and the amount of time since the episode of rheumatic fever, affect the likelihood that valve abnormalities and the murmur will disappear. The type of treatment and the promptness with which treatment is initiated does not affect the likelihood of disappearance of the murmur. In general, the incidence of residual rheumatic heart disease at 10 years is 34% in patients without recurrences but 60% in patients with recurrent rheumatic fever. Disappearance of the murmur, when it occurs, happens within 5 years in 50% of patients. Thus, significant numbers of patients experience resolution of valve abnormalities even 5-10 years after their episode of rheumatic fever. The importance of preventing recurrences of rheumatic fever is evident.

  
  

  Patient Education

  Emphasize the importance of prophylaxis against recurrent streptococcal pharyngitis and rheumatic fever with each patient.

  For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Mitral Valve Prolapse.

  
  

  
  

  
  

   ***the end ***