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Brief Reports Indian Pediatrics 2002; 39:569-573 |
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Prevalence of Positive Throat Cultures for Group A Beta-Hemolytic Streptococci Among School Children in Istanbul |
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Emel Gür
Group A beta hemolytic streptococcus (GABHS) causes many types of infections in children. GABHS tonsillopharyngitis is common among 5-15 year old children. The use of throat culture to confirm the presence of GABHS has become a common pediatric practice by the early 1980s. Penicillin has been used to treat GABHS tonsillopharyngitis for more than 40 years(1). A major objective of antibiotic therapy is to prevent rheumatic fever and possibly reduce the incidence of poststreptococcal glomerulonephritis. Early diagnosis and therapy of the GABHS tonsillopharyngitis is important for prevention of these complications. In our country, in studies performed in the 1980s, GABHS tonsillopharyngitis was a common problem in school children. The aim of our study was to investigate the prevalence of GABHS carriage in throat of school children (both healthy and with tonsillopharyngitis) and risk factors related to carriage/colonization with GABHS. Subjects and Methods This cross sectional study was performed between January ’99-September ’99 by Cerrahpasa Medical Faculty Department of Pediatrics and Ayhan Sahenk Foundation. There are 1,431,797 students in primary schools in Istanbul. When we accept the lowest prevalence as 4% and the margin of sampling error as 1%, at 95% confidence interval, the lowest number of students to represent 1,431,797 students was found to be 1,471. As Istanbul lies in a large area, cluster sampling was performed according to the geographical location of districts. Thus, seven out of 28 central districts in Istanbul were chosen. Of these 7 districts, 4 were in the European side (Behcelievler, Gaziosmanpasa, Gungoren, Sisli) and 3 were in the Anatolian side of Istanbul (Maltepe, Uskudar, Beykoz). In these 7 districs, 14 schools were chosen by systematic sampling. In the schools that were selected the classrooms were randomly chosen according to age groups. Data collection included patient’s age, sex, parent’s education, parent’s working status, number of family members, monthly income of the family and all students were subjected to a detailed physical examination. Throat cultures were obtained from all students by swabbing the pharynx and tonsills, and then were transported to Cerrahpasa Medical Faculty, Department of Pediatrics Microbiology Laboratory in special media. Five per cent sheep blood agar was used for culture and bacitracin sensitivity test was employed for typing. The cases with acute pharyngitis (those with the presence of fever, tonsillopharyngeal erythema and exudate, swollen and tender anterior cervical lymphadenopathy in the absence of rhinorrhea and/or cough) and also those with a positive culture for GABHS received oral penicillin V 250 mg three times daily for 10 days. These cases, who received antimicrobial therapy were scheduled to return to the hospital 4 days after the completion of therapy. During this visit history and physical examination were repeated and throat swabs were again collected from these cases to be cultured. Chi-square and logistic regression analysis and Student ‘t’ test were used to establish the relationship between the prevalence of GABHS and the risk factors. Results One thousand six hundred students were included in the study initially. But, seventeen student’s parents didn’t fill out the questionnaires and they were excluded from this study. Thus the study group was composed of 1583 students between 6-16 years old. The mean age of these students was 10.51 ± 2.36 years and 52.2% of them were male. The sociodemographic features of all the students are shown in Table I. GABHS was grown in 14.7% (232 cases) of all the throat cultures. The rate of GABHS was 13.9% in healthy children. Four hundred twenty two cases (26,7%) had symptoms and physical examination findings of GABHS tonsillo-pharyngitis. In 70 of them, GABHS was grown (16.5%) of throat cultures. Fifty nine of the 70 cases returned to the hospital 4 days after the completion of oral penicillin V treatment. On these visits, none of these patients had symptoms, physical findings of acute pharyngitis and GABHS was eradicated in 55 cases (93.3%). Table I- Relationship Between Prevalence of AGBHS and Sociodemographic Factors
* Numbers of presented data (N) with regard to different parameters are variable in the table due to lack of information on some questionnaires.
When the chi-square analysis was used for statistical analysis, there was only a statistically significant relationship between prevalence of positive throat cultures for GABHS and region. There was a higher prevalence of positive throat cultures for GABHS in European side of Istanbul in comparison with the Anatolian region (17.5% and 10.4%, respectively; p <0.01, Table I). When we investigated the number of students per one classroom, we found that the mean number of students in a classroom was significantly higher in the schools in European side of Istanbul than Anatolian side of Istanbul (43.2 ± 10.1 and 37.1 ± 7.3 respectively; p < 0.05). When the logistic regression analysis was used there was only a significant correlation between prevalence of positive throat cultures for GABHS and region of Istanbul (p < 0.001, Table I). Discussion GABHS causes many types of infections in children; tonsillopharyngitis is by far the most common manifestation in the pediatric population. About 8% to 40% of who had a sore throat, fever and tonsillopharyngeal inflammation had GABHS infection(1). Tuncer et al.(2) found that the prevalence of GABHS among children with acute tonsillopharyngitis was 41%. Cengiz et al.(3) showed that the prevlaence of GABHS among students with acute and chronic upper respiratory throat infection was 23.8% in Turkey. In our study, 26.7% of school children had symptoms of tonsillopharyngitis and the prevalence of GABHS was 16.5% of them. This result is lower than the result of the previous studies in Turkey. This might indicate that the prevalence of GABHS tonsillopharyngitis albeit still high, has been decreasing in time in our country due to somewhat improved living conditions. The rate of GABHS was found to be 4.24%% in Ethiopia, 6% in Las Palmas de Grand Canaria, and 11.5% in Spain among healthy school children(4-6). In our study, the prevalence of GABHS among school children without tonsillopharyngitis was 13.9% and our results are in accordance with those from Spain. In literature, the prevalence of positive throat culture for GABHS is higher in children than in adolescents(1). According to our results, the prevalence of GABHS was 13.4% among children between 6 and 10 years old and 16.0% in adolescents. But, we didn’t find any significant correlation between the prevalence of AGBHS and age (p > 0.05). Crowded living conditions are likely to encourage the transmission of GABHS. Transmission rate of GABHS is approxi-mately 35% in family or school, if the patient is untreated(1). We found that the prevalence of positive throat culture for GABHS was significantly higher in the European side of Istanbul. Penicillin is the gold standard of therapy and it is currently recommended by the American Academy of Pediatrics as the drug of choice for this illness(7-9). However, in recent years, some investigators have reported an increasing incidence of treatment failures with penicillin therapy(10-13). Gerber et al.(7) found that bacteriologic treatment success rate among patients classified clinically as likely to have GABHS pharyngitis who received oral penicillin V in three divided doses for 10 days was 93.3%. Tuncer et al.(2) reported that ten day procain penicillin therapy success was 70.5% and Cengiz et al.(3) reported 24% antibiotic resistance in Turkey. In our study, we found that the success of penicillin treatment was 93.3%, similar to earlier report(7). On investigating the correlation, prevalence of positive throat Culture for GABHS and risk factors, we found only a significant correlation between prevalence of GABHS and region. We showed that the prevalence was higher in European side of Istanbul than Anatolian side of Istanbul. When we looked for the number of students per classroom, we observed that the mean value of number of students per classroom was higher among the schools in European side of Istanbul than in Anatolian side of Istanbul. Thus the number of students per classroom may be an important risk factor for the transmission of GABHS. An interesting finding is that the throat culture positivity for GABHS was not significantly different between healthy and symptomatic children. This might be due to insufficient treatment of children with GABHS tonsillopharyngitis. In conclusion, the prevalence of AGBHS is common among primary school children in Istanbul because of crowded classrooms. Contributors: EG coordinated the study (particularly its design and interpretation) and drafted the paper. SA participated in the data collection. AA and GE helped in drafting the paper. SG and SC participated in the data collection. GC did the statistical analysis. SD did the microbiological investigations. OI supervised the study and helped in drafting the manuscript; he will act as the guarantor for the paper. Funding: Ayhan Sahenk Foundation. Competing interests: None stated.
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