CRITICAL APPRAISAL OF ARTICLE ON HARM. Discontinuing Rheumatic Fever Prophylaxis in Selected Adolescents and Young Adults: A Prospective Study Ximena Berrios , MD; Emilo del Campo , MD; Beatriz Guzman , RN; and Alan L. Bisno , MD .
Discontinuing Rheumatic Fever Prophylaxis in Selected Adolescents and Young Adults: A Prospective Study Ximena Berrios, MD; Emilo del Campo, MD; Beatriz Guzman, RN; and Alan L. Bisno, MD Search terms: penicillin, rheumatic fever, safety, discontinuance
Relevance • Yes. The investigator only included patients ranging in age at study entry from 15 to 44 years (mean, 24.5 years). Patients were entered in the Control and Prevention Program because of an attack of acute rheumatic fever (observed and documented by the Program physicians) that fulfilled the modified Jones criteria or because they were referred from ambulatory clinics with rheumatic valvular heart disease. The latter was confirmed by Program cardiologists who did clinical examinations as well as reviewed electrocardiograms and chest roentgenograms. • (page 3, Methods: Patients, 2nd paragraph) Were there clearly identified comparison groups? Validity
Results What is the magnitude of the association between exposure and outcome?Was the estimate of the risk precise? • Among 59 patients, 48 had completed their period of prophylaxis • There were two recurrences of rheumatic fever during the 3346 patient-months (278.8 patient-years) of follow-up • Recurrence rate: 0.72 (CI, 0.2 to 2.6) per 100 patient-years of prospective surveillance. • Ninety-five percent confidence intervals were determined using the Poisson probability function generator (SAS version 6.03, SAS Institute Inc., 1988). (page 5, Results & page 4, Statistical Analysis)
Are the study patients similar to my own? Clinical Applicability • Yes. (page 1, Abstract: Patients & page 3, Methods: Patients) Is our patient so different from those in the study that its results cannot apply? • No, our patient is the same with the patients included in the study. Therefore, this study can be applied to our patient. What is our patient’s risk of benefit and harm from the exposure? • prone to develop recurrent attacks if they have immunologically significant group A streptococcal throat infections • antibacterial prophylaxis with penicillin has an over-all benefit • possibility of recurrence despite completion of therapy affected by exposure to the pathogens, reliability in reporting promptly to the physician any episodes of pharyngitis, and the incidence of rheumatic fever in the community. • risk for development of or exacerbation of rheumatic heart disease and carditis (page 2, Conclusion & page 8, Discussion)
Resolution to the Scenario What alternative treatments are available? There was no mention in the article of alternative medications. Based on the appraisal, the patient will be advised that prophylactic treatment of Penicillin for her acute rheumatic fever may be discontinued after 5 years given that there was no carditis during the attack. Otherwise, it will have to take 10 years. Individuals who have reached their early twenties, had their most recent attack more than 5 years ago, and are free of rheumatic heart disease can be taken off prophylaxis with relative safety.