Benefit B-NR In patients with VHD who are at high risk of IE, antibiotic prophylaxis is not recommended for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active Table 6. Secondary Prevention of Rheumatic Fever Antibiotics for Prevention Dosage* Penicillin G benzathine 1.2 million U intramuscularly every 4 wk Penicillin V potassium 200 mg orally twice daily Sulfadiazine 1 g orally once daily Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine) Varies *In patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be 10 y or until the patient is 40 y of age (whichever is longer). Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement. Administration every 3 wk is recommended in certain high-risk situations. Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors. Adapted from Gerber et al.1 Table 7. Duration of Secondary Prophylaxis for Rheumatic Fever Type Duration After Last Attack* Rheumatic fever with carditis and residual heart disease (persistent VHD ) 10 y or until patient is 40 y of age (whichever is longer) Rheumatic fever with carditis but no residual heart disease (no valvular disease ) 10 y or until patient is 21 y of age (whichever is longer) Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer) *Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement. Clinical or echocardiographic evidence. VHD indicates valvular heart disease. 