Secondary prophylaxis
People with acute rheumatic fever (ARF) and/or rheumatic heart disease (RHD) are given regular antibiotics to prevent future group A streptococcus (Strep A) infections. This is referred to as ‘secondary prophylaxis’. This reduces the risk of developing ARF again and so helps to prevent developing or worsening RHD. The most effective antibiotic is benzathine benzylpenicillin G (BPG) which is administered as an intramuscular injection. For people who are unable to use intramuscular penicillin, oral antibiotics may be offered. Secondary prophylaxis with regular BPG is the only RHD control strategy shown to be both clinically and cost effective at community and individual levels (Webb et al. 2015; Wyber & Carapetis 2015; Menzies School of Health Research 2025) and needs to be complemented with other primordial and primary prevention activities to eliminate RHD.
BPG is routinely recommended every 28 days to maintain prolonged, low-level benzylpenicillin concentrations. A 21-day antibiotic regimen may be considered by a medical specialist for a small proportion of patients who have breakthrough ARF despite receiving the 28-day regimen or are at high risk of adverse consequences if ARF reoccurs. The duration of the regimen depends on cardiac involvement, severity, and age at the start of BPG, and may last for many years (Menzies School of Health Research 2025).
Adherence to the doctor’s prescription of prophylaxis is critical for effective prevention. Receiving less than 40% of scheduled secondary prophylaxis is equivalent to receiving no prophylaxis at all in terms of reducing recurrent acute rheumatic fever (ARF) episodes, and receiving at least 80% of doses is considered to provide adequate protection against recurrence.
In New South Wales, details of patients prescribed or administered prophylaxis are recorded on the register only if they have consented to be included. This means the New South Wales data are not comparable to data from the other 4 jurisdictions and are reported separately in the following pages.
Menzies School of Health Research (ARF/RHD writing group) (2025) ‘Australian guideline for the prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease’ (Edition 3.3). ISBN 978-1-922770-11-0 (online). Accessed 26 June 2025.
Webb RH, Grant C & Harnden A (2015) Acute rheumatic fever, British Medical Journal, 351(8017), doi:10.1136/bmj.h3443.
Wyber R & Carapetis J (2015) Evolution, evidence and effect of secondary prophylaxis against rheumatic fever, Journal of Practice of Cardiovascular Sciences, 1(1) 9–14, doi:10.4103/2395-5414.157554.