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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 97-102

A study of group a streptococcal pharyngitis among 3–15-year-old children attending clinics for an acute sore throat


1 Department of Pediatrics, Paediatric Cardiology Unit, Federal Medical Centre, Abeokuta, Ogun State, Nigeria
2 Department of Paediatrics, Neonatology Unit, Federal Medical Centre, Abeokuta, Ogun State, Nigeria
3 Department of Microbiology, Federal Medical Centre, Abeokuta, Ogun State, Nigeria
4 Department of Paediatrics, Federal Medical Centre, Abeokuta, Ogun State, Nigeria
5 Department of Family Medicine, Sacred Heart Hospital, Abeokuta, Ogun State, Nigeria
6 Department of Pediatrics, General Hospital, Abeokuta, Ogun State, Nigeria

Date of Web Publication26-Oct-2017

Correspondence Address:
Chinyere Chikodili Uzodimma
Department of Pediatrics, Paediatric Cardiology Unit, Federal Medical Centre, Idi-Aba, Abeokuta, Ogun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_14_17

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  Abstract 

Background: Group A beta-hemolytic Streptococcus (GABHS) is the only causative organism of pharyngitis that is linked to the etiopathogenesis of acute rheumatic fever and rheumatic heart disease.
Aim and Objectives: The objectives of the study were to determine the proportion of GABHS-related pharyngitis, the relationship of clinical symptoms and signs with positive culture outcome, and the antibiotic sensitivity pattern of GABHS among children aged 3–15 years, presenting with symptoms of sore throat in three public hospital settings across Abeokuta.
Methods: Consecutive children aged 3–15 years who present with sore throat or drooling of saliva and any one of these following signs and symptoms were considered eligible: fever >37.5C, cervical lymphadenopathy, inflamed tonsils, and exudative tonsils. All bacitracin susceptible Gram-positive, catalase-negative cocci were classified as Streptococcus pyogenes.
Results: Of 3386 children that were seen, (30) children met the eligibility criteria. Sixteen (53.3%) were males while 14 (46.7%) were females. The mean age of the children was 7.37 years ± 3.146. Cough was the most sensitive symptom (65%) while the presence of exudate was the most specific sign (70%) for GABHS acute sore throat. GABHS was isolated in 66.7% of the children. Streptococcus viridans was found in 4 (13.3%) while the remaining 6 (20%) were sterile. The highest sensitivity was shown to gentamicin and chloramphenicol while amoxicillin-clavulanic acid had the highest resistance (94%).
Conclusion: The proportion of GABHS throat infection is high in this environment. The current findings underscore the need to increase awareness about appropriate throat examination and treatment of sore throat among primary care physicians.

Keywords: Children, Group A beta-hemolytic Streptococcus, rheumatic heart disease, sore throat


How to cite this article:
Uzodimma CC, Dedeke FI, Nwadike V, Owolabi O, Arifalo G, Oduwole O. A study of group a streptococcal pharyngitis among 3–15-year-old children attending clinics for an acute sore throat. Nig J Cardiol 2017;14:97-102

How to cite this URL:
Uzodimma CC, Dedeke FI, Nwadike V, Owolabi O, Arifalo G, Oduwole O. A study of group a streptococcal pharyngitis among 3–15-year-old children attending clinics for an acute sore throat. Nig J Cardiol [serial online] 2017 [cited 2020 Nov 27];14:97-102. Available from: https://www.nigjcardiol.org/text.asp?2017/14/2/97/217270


  Introduction Top


Group A beta-hemolytic Streptococcus (GABHS) is the most important cause of sore throat in children for obvious reasons. It is a causative organism of pharyngitis that is linked to the etiopathogenesis of acute rheumatic fever (ARF) and rheumatic heart disease (RHD).[1],[2] Post-World War II era saw a lot of efforts, research, and interventions in primary and secondary prevention of RHD leading to a drastic reduction in the incidence of the disease, especially in developed countries.[1] Nevertheless, RHD remains among the most common acquired heart diseases in many countries, especially the developing ones.[3],[4] A previous report from Abeokuta showed that RHD persists as an important cause of heart disease.[5],[6] In the report by Ogah et al., RHD constituted 3.7% of cases in the echocardiography registry for all ages.[5] GABHS affects mostly children between the ages of 5 and 15 years.[1],[2] The incidence of Group A streptococci (GAS) pharyngitis varies between and within countries. Sadoh et al.,[7] in Benin, Nigeria, in a hospital-based study, reported GAS pharyngitis in 48% of the population of children aged 3 months to 16 years. Mawak et al.[8] reported GAS pharyngitis in 10% of under-five children attending clinics for upper respiratory tract infections in Jos, Nigeria. In India, the incidence of sore throat and GAS sore throat in a peri-urban slum was 7.05% and 1 episode per child per year, respectively.[9] The latter authors reported seasonal variation with bimodal peak in winter and rainy months.

Concerning clinical manifestations, children with streptococcal pharyngitis present with fever, sore throat, and nonspecific symptoms such as headache, abdominal pain, and vomiting.[10] The most suggestive physical findings are diffuse redness of the tonsils and tonsillar pillars and soft palate petechial mottling, with or without lymphadenitis and follicular exudates.[10] The benefit of antibiotic treatment of GAS pharyngitis is not limited to accelerating clinical recovery. When initiated within 9 days of illness onset, antibiotic is highly effective for the prevention of ARF. Therefore, it is recommended that antibiotic therapy should not be delayed in children with symptomatic GAS pharyngitis.[10] The drug of choice is penicillin.[10] However, allergy to penicillin precludes its use in some patients. Alternatives include amoxicillin, erythromycin, azithromycin, clarithromycin, or first-generation cephalosporins.[10] It is important to remember that there could be local variations in antibiotic susceptibility, and this must be put into careful consideration in choosing antibiotics.

In our practice at Federal Medical Center, Abeokuta, there is a constant occurrence of new cases of RHD in the pediatric outpatient population. This pattern may mirror the prevalence of GAS among children with sore throat. We, therefore, sought to investigate children presenting to the hospital outpatient department with sore throat, to ascertain the proportion of GABHS by microbiological culture of the throat swabs of these children. We believe that this study may sensitize clinicians toward the establishment of treatment guidelines for children with acute sore throat as a means of primary prevention of RHD.

The study therefore aimed to determine the proportion of GABHS-related pharyngitis, the relationship of clinical symptoms and signs with positive culture outcome, and the antibiotic sensitivity pattern of GABHS among children aged 3–15 years, presenting with symptoms of sore throat in the outpatient pediatric population.


  Methods Top


Study design

This was a cross-sectional hospital-based study in the general pediatric outpatient clinics of three main hospitals in Abeokuta-Sacred Heart Hospital, Lantoro, State Hospital, Ijaiye, and Federal Medical Center, Idi-Aba. The study population included all children between ages 3 and 15 years presenting at the various outpatient clinics.

Inclusion and exclusion criteria

Consecutive children aged 3–15 years who presented with sore throat or drooling of saliva and any one of these following signs and symptoms were considered eligible: fever >37.5C, cervical lymphadenopathy, inflamed tonsils, and exudative tonsils. Exclusion criteria were denial of consent and those with significant history of vomiting.

Microbiology

Specimen collection

Throat swabs were collected from all patients recruited into the study using aseptic technique to prevent contamination. All throat swabs were taken either by doctors in the research team or the managing team. A wooden tongue depressor is used to hold the tongue in place. Without touching the sides of the oral cavity or the tongue, a sterile swab stick is used to swab the posterior pharynx and tonsillar arches. The specimens were taken to the laboratory by a research assistant immediately after collection.

Laboratory methods

The tests were carried out in the Bacteriology Laboratory of the Federal Medical Center, Abeokuta.

Laboratory procedure

A Gram-stain was done on smears made from specimens and then viewed under the light microscope at ×100. Classically, the GAS are Gram-positive cocci.[11]

Culture and identification

The specimens were inoculated on sheep blood Agar and incubated at 35–37°C for 18–24 h. Streptococcus pyogenes grows as B-hemolytic colonies on blood agar.[11]

Characterization

All Gram-positive cocci isolated were tested for catalase. All catalase-positive, Gram-positive cocci were further tested for susceptibility to bacitracin. All bacitracin susceptible Gram-positive, catalase-negative cocci were classified as S. pyogenes.[11]

Ethical considerations

The Ethics and Research Committee of the Hospital approved the study.

Data collection

Sociodemographic data were recorded in a pro forma during recruitment, and all data forms and laboratory request forms were clearly labeled with each patient's name and identification number. Later, laboratory results were received and updated accordingly. All results were provided to the medical team to contribute toward the patient care.

Data analysis

Data were analyzed using SPSS version 23 (Armonk, NY, IBM Corp). Descriptive statistics were used for the summary of the data. Student's t-test was used for multivariate analysis. P < 0.05 was statistically significant.


  Results Top


Over a period of 8 months from April to November 2014, a total of 3386 children aged between 3 and 15 years were seen in the general outpatient clinics of the three centers. Thirty children met the inclusion criteria and were recruited into the study, giving an incidence of 0.8% for acute sore throat in this age group.

General characteristics of the study population

Of the children, 16 (53.3%) were males while 14 (46.7%) were females giving male-to-female ratio of 1.14:1. The mean age of the children was 7.37 ± 3.14 years (range 3–14 years). Majority of the children (76.7%) came from households comprising five or less members; most slept in the same room with three other persons or less, and the apartments were mostly well ventilated. The distribution of these characteristics is depicted in [Table 1].
Table 1: General characteristics of the study population

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Distribution and relationship of clinical signs and Group A beta-hemolytic Streptococcus culture outcome

The clinical features of the children are shown in [Table 2]. The three most frequent features were fever, cervical adenopathy, and cough while the presence of exudates was the least frequent clinical sign. Only four persons (13.3%) reported a history of sore throat symptoms in any other siblings within the preceding 2 weeks of this study while nearly half of the children (43.3%) had received antibiotics at home or from a chemist before presentation. On sensitivity and specificity of clinical signs, cough was the most sensitive symptom while the presence of exudate was the most specific sign for GABHS acute sore throat.
Table 2: Distribution, sensitivity, and specificity of clinical features in Group A beta-hemolytic Streptococcus acute sore throat

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Culture outcomes

GABHS was isolated in 66.7% of the children. Streptococcus viridans was found in 4 (13.3%) while the remaining 6 (20%) were sterile. As shown in [Figure 1], the age group with the highest proportion of GABHS was age 3–6 years. The age group of 3–6 years was associated with six times higher likelihood of isolating GABHS than other age groups (P = 0.163). Among the age groups, 71%, 66%, and 60%, respectively, of ages 3–6, 7–10, and >10 years yielded GABHS-positive throat cultures. The youngest age group (3–6 years) also had the highest frequency of S. viridans which is a normal flora [Figure 2].
Figure 1: Distribution of Group A beta-hemolytic Streptococcus sore throat by age group (original)

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Figure 2: Relationship between culture outcomes and age (original)

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Relationship between Group A beta-hemolytic Streptococcus culture-positive and selected sociodemographic characteristics

The number of bedrooms and size of household showed significant relationship with positive GABHS throat swab isolate. Having fewer bedrooms increased the chances of having a positive culture (χ2 = 4.268, P = 0.038). However, with size of household, majority of the population (76.7%) ab initio reported small household sizes of 1–5 [Table 1]. The number of persons sleeping in the same room and number of windows did not show significant relationship with the GABHS culture-positive throat swabs [Table 3].
Table 3: Relationship between Group A beta-hemolytic Streptococcus outcome and selected sociodemographic characteristics

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Antibiotic susceptibility patterns

Out of the 20 specimens that yielded S. pyogenes, three had missing data on antibiotic susceptibility. [Table 4] summarizes the pattern of susceptibility. The overall antibiotic susceptibility was low for all five tested drugs. The highest sensitivity was to gentamicin and chloramphenicol (35.2% each) followed by erythromycin (23.4%) and ceftriaxone (17.6%) while the least susceptibility was to amoxicillin-clavulanic acid (5.8%).
Table 4: Antibiotic sensitivity pattern

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  Discussion Top


There appears to be a consensus that antibiotic treatment of S. pyogenes is an effective primary prevention strategy for ARF and RHD, both of which are its nonsuppurative complications. However, following the drastic reduction of RHD burden, especially in developed countries of the world, there seem to be divided opinions on whether acute sore throat should be investigated and treated with antibiotics as a means of primary prevention of ARF/RHD or not.[12],[13] Whereas ARF and RHD are rarely seen in the developed countries and therefore weaken the basis for antibiotic treatment, RHD remains a major cause of acquired heart diseases in developing countries and may be nonuniformly distributed even within the same country. As noted earlier in this article, our hospital records, though unpublished, show persistent new cases of ARF/RHD, and therefore, the need to continue to investigate and treat GABHS pharyngitis is key to control of RHD in developing countries.

The current study found that 0.8% of 3–15-year-old presentations in the general pediatric outpatient clinic were due to acute sore throat, and S. pyogenes was identified as the causative agent in 66.7% of the children. This proportion of S. pyogenes is quite high and may be the reason for the observation of ARF/RHD new cases in our hospital. Sadoh et al. in Benin,[7] Nigeria, reported that 48.72% of the bacterial isolates from throat swabs were beta-hemolytic streptococci, but no Lancefield grouping was done (Group A, B, C, and G are beta-hemolytic). Another study in Jos, Nigeria, by Mawak et al.[8] reported a much lower figure of 10.45% for S. pyogenes among under-five age group. Conversely, in the present study, the results show highest occurrence of S. pyogenes among children aged 3–6-year-old. Over 70% of this age group had S. pyogenes, and they accounted for as much as 50% of the S. pyogenes culture-positive throat swabs. The presentation in these three hospitals for sore throat symptom is low, and this could reflect poor health-seeking behavior, socioeconomic disposition, or poor health intelligence in this community. This low rate is supported by the finding that application of self- or chemist-prescribed antibiotics in this study was common, implying that most people would not have presented to hospital at all. The need for a community-based larger study and community-based primary preventive programs is emphasized here.

It is important to recognize that the majority (about 80%) of the children in this study lived in well-spaced and ventilated apartments and their family sizes were mostly within five in number. Similarly, in the Benin study,[7] about 70% of the population came from upper and middle social classes. Nonetheless, those who lived in apartments with fewer bedrooms had significantly more positive cultures than not. Larger community-based studies are needed to clarify if there has been a shift in the sociodemographic predisposition to streptococcal sore throat that may also impact on its immunological complications. On the other hand, we recognize that being a hospital-based study, the fundamental issue of affordability of hospital services excludes greater number of the lower social classes from institutionalized health-care access. Hence, this could be reflecting skewness of health-care affordability in which the lower social class has been excluded from the orthodox health institutions due to high-cost and poor health insurance coverage.

Although the sensitivity and specificity of clinical signs and symptoms for identification of S. pyogenes sore throat were low, the presence of exudates was the most specific clinical sign with specificity of 70%. A combination of cough and exudates should raise high suspicion for S. pyogenes. The study by Sadoh et al.[7] reported similarly that cough and exudates had the highest specificity among other signs and symptoms. Both findings, therefore, emphasize the importance of throat examination in the management of these children.

Regarding antibiotic sensitivity pattern, we reported five antibiotics including ceftriaxone, erythromycin, gentamicin, amoxicillin-clavulanic acid, and chloramphenicol. The high rate of drug resistance is disturbing with that of amoxicillin-clavulanic acid approaching 100%. The finding that nearly half of the study population had been treated with antibiotics before presentation gives great concern about antibiotics abuse.


  Conclusion Top


The current study has shown that the proportion of GABHS throat infection is high in this environment. The high prevalence reflects the actual situation in the surrounding communities from which our patients come. Therefore, most children between the ages of 3 and 6 years presenting with sore throat and exudates are likely to have GABHS. There is high rate of antibiotic resistance in this study. The current findings undermine the need to increase awareness about appropriate throat examination and treatment of sore throat among primary care physicians as well the need to embark on larger community-based studies to further clarify some of the concerns raised by this study. Efforts to use different sets of sensitivity discs for testing antibiotic susceptibility are necessary to guide antibiotic decisions further.

Acknowledgments

We deeply appreciate the contribution of our research assistant, Miss. Seun, who went around to transport specimen to laboratory. We are grateful to Drs. Ige and Sogunle for their support at the family medicine clinics at FMC Abeokuta and Drs. Alao, Alli, and Anifowose of FMC, Abeokuta, for collecting throat swabs at the various clinics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Floyd WD. History of hemolytic streptococci. In: Stevens D, Kaplan E, editors. Streptococcal Infections: Clinical Aspects, Microbiology, and Molecular Pathogenesis. New York: Oxford University Press; 2000. p. 1-15.  Back to cited text no. 1
    
2.
Pruthvish S. Epidemiology of Group A streptococcal infections, rheumatic fever and rheumatic heart diseases and role of WHO. In: Vijayalakshmi IB, editor. Acute Rheumatic Fever and Chronic Rheumatic Heart Diseases. New Delhi: Jaypee Brothers Medical; 2011. p. 35-46.  Back to cited text no. 2
    
3.
Mendis S, Puska P, Norrving B, editors. Global Atlas on Cardiovascular Disease Prevention and Control. Geneva: World Health Organization (in collaboration with the World Heart Federation and World Stroke Organization); 2011. Available from: http://www.world-heartfederation.org/fileadmin/user_upload/documents/Fact_sheets/2012/RHD.pdf. [Last accessed on 2016 Jul 03].  Back to cited text no. 3
    
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Wilson SE, Chinyere UC, Queennette D. Childhood acquired heart disease in Nigeria: An echocardiographic study from three centres. Afr Health Sci 2014;14:609-16.  Back to cited text no. 4
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Ogah O, Adegbite G, Akinyemi R, Adesina J, Alabi A, Falase A, et al. Epidemiology of acute heart failure in Southern Nigeria: Data from Abeokuta Heart Failure Registry. Circulation 2010;122:e229.  Back to cited text no. 5
    
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Ogah O, Adegbite G, Udoh S, Ogbodo E, Ogah F, Adesomowo A, et al. Chronic rheumatic heart disease in Abeokuta, Nigeria: Data from Abeokuta Heart Disease Registry. Niger J Cardiol 2014;11:98-103.  Back to cited text no. 6
    
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Sadoh WE, Sadoh AE, Oladipo AO, Okunola OO. Bacterial isolates of tonsillitis and pharyngitis in paediatric casualty setting. J Med Biomed Res 2008;7:37-44.  Back to cited text no. 7
    
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Mawak JD, Ewelike IC, Lar PM, Zumbes HJ. Bacterial etiologic agents associated with upper respiratory tract infections in children (under five years) attending selected clinics in Jos, Nigeria. Highland Med Res J 2006;4:22-30.  Back to cited text no. 8
    
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Nandi S, Kumar R, Ray P, Vohra H, Ganguly NK. Group A streptococcal sore throat in a periurban population of Northern India: A one-year prospective study. Bull World Health Organ 2001;79:528-33.  Back to cited text no. 9
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Robert RT. Acute pharyngitis. In: Behrman RE, Kleigman RM, Bonita FS, Joseph W, Nina FS, editors. Nelson Textbook of Pediatrics. 20th ed. Philadelphia: Elsevier; 2016. p. 2018-9.  Back to cited text no. 10
    
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Cheesbrough M. District Laboratory Practice in Tropical Countries. 2nd ed. Cambridge: Cambridge University Press; 2006. p. 76-9.  Back to cited text no. 11
    
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ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012;18 Suppl 1:1-28.  Back to cited text no. 12
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Del Mar C. Managing sore throat: A literature review. II. Do antibiotics confer benefit? Med J Aust 1992;156:644-9.  Back to cited text no. 13
    


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