风湿热.docx

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风湿热

AHAScientificStatement

PreventionofRheumaticFeverandDiagnosisandTreatmentofAcuteStreptococcalPharyngitis

AScientificStatementFromtheAmericanHeartAssociationRheumaticFever,Endocarditis,andKawasakiDiseaseCommitteeoftheCouncilonCardiovascularDiseaseintheYoung,theInterdisciplinaryCouncilonFunctionalGenomicsandTranslationalBiology,andtheInterdisciplinaryCouncilonQualityofCareandOutcomesResearch:

EndorsedbytheAmericanAcademyofPediatrics*

MichaelA.Gerber,MD,Chair;RobertS.Baltimore,MD;CharlesB.Eaton,MD,MS;MichaelGewitz,MD,FAHA;AnneH.Rowley,MD;StanfordT.Shulman,MD;KathrynA.Taubert,PhD,FAHA

  Abstract

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Abstract

Introduction

PreventionofInitialAttacks...

PreventionofRecurrentAttacks...

References

PrimarypreventionofacuterheumaticfeverisaccomplishedbyproperidentificationandadequateantibiotictreatmentofgroupAβ-hemolyticstreptococcal（GAS）tonsillopharyngitis.DiagnosisofGASpharyngitisisbestaccomplishedbycombiningclinicaljudgmentwithdiagnostictestresults,thecriterionstandardofwhichisthethroatculture.Penicillin（eitheroralpenicillinVorinjectablebenzathinepenicillin）isthetreatmentofchoice,becauseitiscost-effective,hasanarrowspectrumofactivity,andhaslong-standingprovenefficacy,andGASresistanttopenicillinhavenotbeendocumented.Forpenicillin-allergicindividuals,acceptablealternativesincludeanarrow-spectrumoralcephalosporin,oralclindamycin,orvariousoralmacrolidesorazalides.TheindividualwhohashadanattackofrheumaticfeverisatveryhighriskofdevelopingrecurrencesaftersubsequentGASpharyngitisandneedscontinuousantimicrobialprophylaxistopreventsuchrecurrences（secondaryprevention）.Therecommendeddurationofprophylaxisdependsonthenumberofpreviousattacks,thetimeelapsedsincethelastattack,theriskofexposuretoGASinfections,theageofthepatient,andthepresenceorabsenceofcardiacinvolvement.Penicillinisagaintheagentofchoiceforsecondaryprophylaxis,butsulfadiazineoramacrolideorazalideareacceptablealternativesinpenicillin-allergicindividuals.Thisreportupdatesthe1995statementbytheAmericanHeartAssociationRheumaticFever,Endocarditis,andKawasakiDiseaseCommittee.ItincludesnewrecommendationsforthediagnosisandtreatmentofGASpharyngitis,aswellasforthesecondarypreventionofrheumaticfever,andclassifiesthestrengthoftherecommendationsandlevelofevidencesupportingthem.

KeyWords:

AHAScientificStatements•pediatrics•infectiousdiseases•prevention•rheumaticheartdisease•rheumaticfever•streptococcalpharyngitis

  Introduction

Top

Abstract

Introduction

PreventionofInitialAttacks...

PreventionofRecurrentAttacks...

References

Thisscientificstatementisanupdateofa1995statementonpreventionofrheumaticfeverbythiscommittee.1PreventionofbothinitialandrecurrentattacksofrheumaticfeverdependsoncontrolofgroupAβ-hemolyticstreptococcal（GAS）tonsillopharyngitis（strepthroat）.Preventionoffirstattacks（primaryprevention）isaccomplishedbyproperidentificationandadequateantibiotictreatmentofstreptococcalinfections.TheindividualwhohashadanattackofrheumaticfeverisathighriskofdevelopingrecurrencesaftersubsequentGASpharyngitisandneedscontinuousantimicrobialprophylaxisforyearstopreventsuchrecurrences（secondaryprevention）.2–6

Indevelopingareasoftheworld,acuterheumaticfeverandrheumaticheartdiseaseareestimatedtoaffectnearly20millionpeopleandaretheleadingcausesofcardiovasculardeathduringthefirst5decadesoflife.7Incontrast,theincidenceofacuterheumaticfeverhasdecreaseddramaticallyinmostdevelopedcountries.8IncertainareasoftheUnitedStates,afewlocalizedoutbreaksincivilianandmilitarypopulationswerereportedinthe1980s.8,9Thisreappearanceofacuterheumaticfeverservesasareminderoftheimportanceofcontinuedattentiontopreventionofrheumaticfeverinthisandotherdevelopedcountries;however,currently,theoverallincidenceofacuterheumaticfeverremainsverylowinmostareasoftheUnitedStates.10,11Therecommendationsinthepresentstatementareprimarilybasedonthisassumption.PhysicianspracticinginareasoutsidetheUnitedStateswithahigherincidenceofacuterheumaticfeverorinareasoftheUnitedStatesexperiencinganoutbreakofacuterheumaticfeverneedtotakethisintoconsideration.

Thewritinggroupwaschargedwiththetaskofperforminganassessmentoftheevidenceandassigningaclassificationofrecommendationsandalevelofevidence（LOE）toeachrecommendation.TheAmericanCollegeofCardiology/AmericanHeartAssociation（AHA）classificationsy