Group A Beta-hemolytic Streptococci Research Articles

A case report of hemolytic streptococcal gangrene in the danger triangle of the face with thrombocytopenia and hepatitis

BackgroundHemolytic streptococcus gangrene is a life threatening invasive bacterial infection. Hemolytic streptococcus gangrene in the danger triangle of the face is too lethal to operate. A case of the confirmed hemolytic streptococcus gangrene in the danger triangle of the face caused by Group A beta-hemolytic streptococcus (GAS) in 20-months old boy is presented to draw attention of clinicians to this uncommon but frequently fatal infection.Case presentationPreviously healthy 20 months old boy suddenly developed paranasal gangrene on the left side of the danger triangle of the face, followed by rapidly progressive thrombocytopenia and hepatitis. The clinical features, liver function, and hematological and serological parameters resembled to a description of streptococcal toxic shock syndrome (STSS). Aggressive antibiotics, substitutional and supportive therapy were conducted without surgical debridement of facial tissues. Prompt diagnosis and aggressive timely treatment completely cured the disease in 28 days.ConclusionsThe present case report demonstrates prompt diagnosis and timely treatment as a strategy to cure the fatal hemolytic streptococcus gangrene located in too risky body part to operate.

Analysis of the tonsillar microbiome in young adults with sore throat reveals a high relative abundance of Fusobacterium necrophorum with low diversity.

Fusobacterium necrophorum (Fn), a gram-negative anaerobe, is increasingly implicated as an etiologic agent in older adolescents and young adults with sore throat. Inadequately treated Fn pharyngitis may result in suppurative complications such as peritonsillar abscess and Lemierre’s syndrome. Data from the literature suggest that the incidence of life-threating complications in these age groups from Fn pharyngitis (Lemierre’s syndrome) in the United States exceeds those associated with group A beta-hemolytic streptococcal (GAS) pharyngitis (acute rheumatic fever). Using real-time PCR, we previously reported about a 10% prevalence of Fn in asymptomatic medical students and about 20% in students complaining of sore throat at a university student health clinic (p = 0.009). In this study, a comprehensive microbiome analysis of the same study samples confirms that Fn pharyngitis was more common than GAS pharyngitis. Eighteen patients were found to have Fn OTU values exceeding an arbitrary cutoff value of 0.1, i.e. greater than 10% of total sequences, with five subjects reaching values above 0.7. By contrast only 9 patients had GAS OTU values greater than 0.1 and none exceeded 0.6. When the data were analyzed using five separate assessments of alpha diversity, in each case for Fn there were statistically significant differences between Fn positive_high (OTU abundance > 0.1) vs control, Fn positive_high vs Fn negative (OTU abundance = 0), Fn positive_high vs Fn positive_low (OTU abundance > 0 and < 0.1). When the data were analyzed using three beta diversity indexes (Bray-Curtis, weighted unifrac, and unweighted unifrac), there were statistically significant differences between Fn positive_high (OTU abundance ≥ 0.1) vs control for all three. Statistically significant differences remained if we chose somewhat different OTU abundance cutoffs of 0.05 or 0.15. We conclude that Fn appears to play a dominant role in bacterial pharyngitis in the older adolescent and young adult age groups and that the development of a productive mucosal infection with Fn is linked to a significant decrease in the diversity of the associated tonsillar microbiome.

Oral Clindamycin as Drug of Choice for Scabies Patients with Secondary Bacterial Infections in West Java, Indonesia

The aim of this study was to identify the causative secondary bacterial infection in scabies and its susceptibility against systemic antimicrobials. We performed a cross-sectional descriptive study of 34 scabies patients clinically diagnosed by investigators through consecutive sampling in one District Hospital in West Java, Indonesia from January to March 2017. The secondary bacterial infection was confirmed by Gram staining. Bacterial culture was derived from intact pustules, then identified using Vitek® 2 system, including its susceptibility against 30 systemic antimicrobials. The result of bacterial identification consisted of 48.89% Group A Beta-Hemolytic Streptococcus (GABHS), 44.44% Staphyloccocus aureus (S. aureus), 4.44% Staphylococcus epidermidis (S. epidermidis) and 2.22% Klebsiella pneumoniae (K. Pneumoniae). All bacterias were sensitive to carbapenem group, however resistant to cephradine and kanamycin. The overall percentages of GABHS sensitivity to the tested antibiotics were as follows: 95.45% for chloramphenicol and ceftriaxone, 90.91% for amoxicillin/clavulanate, 86.36% for clindamycin, cloxacillin, cefotaxime, 72.27% for ciprofloxacin and methicillin. Sensitivity of S. aureus to the antibiotics were as follows: 100.00% for methicillin, 95.00% for clindamycin and cloxacillin, 90.00% for ciprofloxacin and levofloxacin, 85.00% for cotrimoxazole and 75.00% for ceftriaxone. The sensitivity of S. epidermidis to clindamycin, amoxicillin/clavulanate and methicillin were 100.00%. All of K. pneumoniae (100.00%) were sensitive to ciprofloxacin, cotrimoxazole, ampicillin/sulbactam, cefazolin, ceftriaxone, ceftazidime and cefepime. The most common etiology of secondary infection in scabies were GABHS and S. aureus with varying sensitivity and oral clindamycin is a drug of choice which can be given to pediatric or adults patients.

Rapid antigen diagnostic testing for the diagnosis of group A beta-haemolytic streptococci pharyngitis.

It is difficult to make a diagnosis of group A beta-haemolytic streptococci (GABHS) pharyngitis solely on clinical findings. The McIssac scoring system has been recommended as a reliable clinical tool for diagnosis. The rapid antigen detection test (RADT) has been shown to considerably increase the number of patients who are appropriately treated for streptococcal pharyngitis, compared with the use of traditional throat cultures. It also reduces the time to start treatment. We evaluated the diagnostic utility of RADT in comparison with throat swab culture. Using the McIssac scoring system, RADT and throat swab cultures in those with a McIssac score of 3 or more, we evaluated 165 children (aged 2-15 years) with a clinical diagnosis of pharyngitis. GABHS pharyngitis was confirmed in 41 (24.8%) by throat swab culture and RADT was positive in 39(23.6%). Only in 2 (4.9%) children, RADT was negative but throat swab was positive. The sensitivity of RADT was 89.7% and specificity was 98.4% with a positive predictive value of 94.6%, negative predictive value of 96.9% and diagnostic accuracy of 96.4%. RADT performed was observed to have high sensitivity and sensitivity for the diagnosis of GABHS pharyngitis in contrast to an earlier report from India. Our observations suggest that using RADT as a point-of-care test is reliable and cost-effective and needs to be propagated in Indian settings where facilities for throat swab culture are not routinely available and also because clinical diagnosis based on scoring systems are comparatively less reliable.

Differential binding of antibodies in PANDAS patients to cholinergic interneurons in the striatum

Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus, or PANDAS, is a syndrome of acute childhood onset of obsessive-compulsive disorder and other neuropsychiatric symptoms in the aftermath of an infection with Group A beta-hemolytic Streptococcus (GABHS). Its pathophysiology remains unclear. PANDAS has been proposed to result from cross-reactivity of antibodies raised against GABHS with brain antigens, but the targets of these antibodies are unclear and may be heterogeneous. We developed an in vivo assay in mice to characterize the cellular targets of antibodies in serum from individuals with PANDAS. We focus on striatal interneurons, which have been implicated in the pathogenesis of tic disorders. Sera from children with well-characterized PANDAS (n = 5) from a previously described clinical trial (NCT01281969), and matched controls, were infused into the striatum of mice; antibody binding to interneurons was characterized using immunofluorescence and confocal microscopy. Antibodies from children with PANDAS bound to ∼80% of cholinergic interneurons, significantly higher than the <50% binding seen with matched healthy controls. There was no elevated binding to two different populations of GABAergic interneurons (PV and nNOS-positive), confirming the specificity of this phenomenon. Elevated binding to cholinergic interneurons resolved in parallel with symptom improvement after treatment with intravenous immunoglobulin. Antibody-mediated dysregulation of striatal cholinergic interneurons may be a locus of pathology in PANDAS. Future clarification of the functional consequences of this specific binding may identify new opportunities for intervention in children with this condition.

Evidence Based Practice in Using Antibiotics for Acute Tonsillitis in Primary Care Practice.

The increased use of antibiotics for acute tonsillitis is a public health problem. 80% of the antibiotic prescriptions for acute tonsillitis are done in the Primary Care practice (PCP). The inappropriate use of the antibiotic causes bacterial resistance and treatment failure. Only patients with acute tonsillitis caused by Group A beta-hemolytic streptococcus (GAS) have benefit of the antibiotic treatment, which is a predict cause in 5-20%. In order to assess the antibiotic prescribing for acute tonsillitis by the doctors in the PCP in Macedonia we use the data from the national project about antibiotic prescribing for acute respiratory tract infections which was conducted in November 2014 during a period of 4 weeks as part of the E-quality program sponsored by the IPCRG. 86 general practitioners from Macedonia have participated. The group of 1768 patients, from 4 months to 88 years of age, with diagnosis of acute tonsillitis was analyzed. The antibiotic prescriptions according to the Centor score criteria were compared to the Cochran's guidelines which are translated and recommended as national guidelines. 88.8% of the patients with acute tonsillitis were treated with antibiotics, of which 52.9% with Centor score 0 to 2 were treated inappropriate. The diagnosis is mostly made based on the clinical picture and the symptoms. Only (23.6%) of the patients were treated with antibiotics (Penicillin V and cephalexin) according to the guidelines. We concluded that there is a low adherence to the national guidelines. The clinical assessment is not accurate in determining the etiology. Also, there is a high nonadherence in prescribing the first choice of antibiotics. We emphasize the need to change the general practitioners' prescription behavior according to the guidelines.

Pneumonia and Streptococcal Toxic Shock Syndrome Due to Group A Streptococci：A Case Report

A 71-year-old woman who was undergoing immunosuppressive therapy presented with a 7-day history of productive cough and 2-day history of fever. She was diagnosed with severe pneumonia and septic shock. Meropenem, azithromycin, large amounts of fluids, and noradrenaline were administered, and high-flow nasal cannula oxygen therapy was provided. The gross appearance of the aspirated sputum was ginger-like, and the gram-positive cocci in chains were identified as group A beta-hemolytic streptococci (GAS), Streptococcus pyogenes. The blood sample culture test revealed negative results. Based on Stevens' criteria, the patient was finally diagnosed as having streptococcal toxic shock syndrome (STSS). Antibiotics were switched to ampicillin/sulbactam and clindamycin as an antitoxin treatment, and the patient was discharged on day 33. Serotypes of GAS were T1, M1, and emm1. Superantigens spe A, spe B, and spe F were present, and spe C was absent. These observations were compatible with the clinical features of hypotension. GAS is an uncommon cause of community-acquired pneumonia, which when potentially complicated with STSS can lead to a high mortality rate, and the rapid progression is particularly a striking feature. We should be aware that GAS can cause pneumonia, and antitoxin treatment can play a key role in STSS management.

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

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.

Clinical value of antistreptolysin O levels in adult patients with tonsillitis: report I.

To assess the clinical value of antistreptolysin O (ASO) level in adult patients with acute tonsillitis of group A beta-hemolytic streptococcus (GABHS) etiology and its interaction with the Centor score and throat cultures data. ASO antibody titers and throat cultures were obtained from 260 adult patients with acute tonsillitis of GABHS etiology initially proven by the Centor score. The results were compared with the group of 100 adult patients with recurrent tonsillitis who underwent tonsillectomy and with the group of 100 healthy adults. Throat cultures revealed GABHS-positive results in 69 acute cases (26.5%) and in 24 recurrent cases (24%), i.e., with no significant differences between the groups (p=0.845). There was no significant difference between cases with GABHS-positive and with GABHS-negative throat culture in ASO titers results (mean 250 and 280, respectively, p=0.44) but these titers were significantly higher than established normative data (p<0.01). For the group of recurrent tonsillitis cases, the mean ASO titer was 363 being significantly higher in comparison with acute cases (p=0.015). The ASO antibody titers are significantly higher than normative ranges in cases of acute tonsillitis in adults. The detection of the elevated titers may lead to early antibiotherapy to tonsillitis. The Centor score is supported by the ASO data and less supported by throat cultures data. Further research should reveal if these titers might have predictive value for possible further recurrence or serve as an indicator for tonsillectomy in cases of recurrent tonsillitis.

Different antibiotic treatments for group A streptococcal pharyngitis.

Antibiotics provide only modest benefit in treating sore throat, although effectiveness increases in participants with positive throat swabs for group A beta-haemolytic streptococci (GABHS). It is unclear which antibiotic is the best choice if antibiotics are indicated.We assessed the comparative efficacy of different antibiotics on clinical outcomes, relapse, complications and adverse events in GABHS tonsillopharyngitis.We searched The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL 2010, Issue 3) which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2010) and EMBASE (1974 to August 2010).Randomised, double-blind trials comparing different antibiotics reporting at least one of the following: clinical cure, clinical relapse, complications, adverse events.Two authors independently screened trials for inclusion and extracted data.Seventeen trials (5352 participants) were included; 16 compared with penicillin (six with cephalosporins, six with macrolides, three with carbacephem and one with sulfonamides), one trial compared clindamycin and ampicillin. Randomisation reporting, allocation concealment and blinding were poor.There was no difference in symptom resolution between cephalosporins and penicillin (intention-to-treat (ITT) analysis; N = 5; n = 2018; odds ratio for absence of resolution of symptoms (OR) 0.79, 95% confidence interval (CI) 0.55 to 1.12). Clinical relapse was lower with cephalosporins (N = 4; n = 1386; OR 0.55, 95% CI 0.31 to 0.99); overall number needed to treat to benefit (NNTB) 50), but found only in adults (OR 0.42, 95% CI 0.20 to 0.88; NNTB 33). There were no differences between macrolides and penicillin. Carbacephem showed better symptom resolution post-treatment (N = 3; n = 795; OR 0.70, 95% CI 0.49 to 0.99; NNTB 14), but only in children (N = 2; n = 233; OR 0.57, 95% CI 0.33 to 0.99; NNTB 8.3). Children experienced more adverse events with macrolides (N = 1, n = 489; OR 2.33; 95% CI 1.06 to 5.15).Evidence is insufficient for clinically meaningful differences between antibiotics for GABHS tonsillopharyngitis. Limited evidence in adults suggests cephalosporins are more effective than penicillin for relapse, but the NNTB is high. Limited evidence in children suggests carbacephem is more effective for symptom resolution. Data on complications are too scarce to draw conclusions. Based on these results and considering the low cost and absence of resistance, penicillin can still be recommended as first choice.

The effectiveness of the McIsaac clinical decision rule in the management of sore throat: an evaluation from a pediatrics ward.

Sore throats may be due to either viral or group A beta hemolytic streptococcus (GABHS) infections; but diagnosis of the etiology of a sore throat is difficult, often leading to unnecessary antibiotic prescriptions and consequent increases in bacterial resistance. Scoring symptoms using the McIsaac clinical decision rule can help physicians to diagnose and manage streptococcal infections leading to sore throat and have been recommended by the Ministry of Health, Malaysia. In this paper, we offer the first assessment of the effectiveness of the McIsaac rule in a clinical setting in Malaysia. This study is a retrospective review of 116 pediatric patients presenting with sore throat. Group A comprised patients before the implementation of the McIsaac rule and Group B comprised patients after the implementation. Unnecessary throat swab cultures were reduced by 40% (P = 0.003). Redundant antibiotic prescriptions were reduced by 26.5% (P = 0.003) and the overall use of antibiotics was reduced by 22.1% (P = 0.003). The pediatricians' compliance rate to McIsaac rule criteria was 45% before implementation of the McIsaac rule, but improved to 67.9% (P = 0.0005) after implementation. The McIsaac rule is an effective tool for the management of sore throat in children in Malaysia.

The 2015 Jones Criteria for Acute Rheumatic Fever- Need for a Critical Reappraisal.

Acute rheumatic fever (ARF), a non-suppurative complication of group A beta hemolytic streptococcus (GAS), continues to be an important cause of acquired heart diseases in children [1, 2]. Whilst the burden of rheumatic heart disease (RHD) has significantly reduced in developed countries, it still continues to be a major health problem in developing countries [2]. Prevalence of RHD in India is estimated to be 0.67/1000 children in a recent school based survey [2, 3]. Over past 50 y, significant developments have occurred in diagnosis and management of ARF. One of the major changes noted in the diagnosis of ARF is the utility of Echocardiogram and Doppler (E&D) studies for detection of clinically unrecognizable carditis for the diagnosis of ARF [4]. Subclinical carditis (SC) is a condition where clinical cardiac examination is completely normal and only E&D studies pick up the valvular abnormalities. Diagnostic criteria for ARF was initially put forth by Dr. T. Duckett Jones in the year 1944. The criteria have been revised and updated several times, and the most recent update of the Jones Criteria have been released by the American Heart Association in May 2015 [5, 6]. Main aim of these guidelines has been to have a uniform diagnostic criteria across the globe and to prevent over-diagnosis. However, even the most recent version has several shortcomings for clinical application in developing countries where the vast majority of patients with ARF are likely to be diagnosed and managed (Table 1). Recent revision of Jones Criteria for diagnosis of ARF has suggested that echocardiography be performed in all cases of suspected ARF [6]. Subclinical carditis is now considered one of the major criteria for diagnosis of ARF. The addition of SC as the major criteria is based on large numbers of good quality evidence from both developed and developing countries around the globe, which suggested that E&D based screening is more sensitive than clinical examination for detection of carditis [6]. However, it is prudent to note that long term outcome of subclinical carditis is not clearly known and it may well represent only a transient phenomenon [7]. Robust data on long term follow-up of patients with subclinical carditis is lacking. This recommendation in the 2015 criteria is, therefore, open to debate and controversy. Existing data on follow-up studies indicate that subclinical carditis may worsen to RHD, may remain unchanged, or may also improve over time [2, 4, 7]. Moreover, facilities for E&D based screening for carditis in patients with suspected ARFwould not be easily available at the point of care in most developing countries. Interpretation of the E&D studies would also need an experienced cardiologist/echocardiographer, who may not be easily available in all centres. If the new criteria have to be accepted and implemented, then a seemingly large number of patients may need referral to higher centres where experts in cardiology are likely to be available. This is likely to put additional burden on the scarce health care resources available in these countries. Though the criteria for pathological valve regurgitation are very clear in the guidelines [6], the line between physiological and pathological abnormalities of cardiac valves appears thin and nebulous when it comes to clinical practice. And unless echocardiography has been performed by an experienced pediatric cardiologist/echocardiographer who is familiar with the finer nuances of cardiac involvement in ARF, it may be difficult for the attending physician to interpret the * Pandiarajan Vignesh vigimmc@gmail.com

THE INCIDENCE OF GROUP A BETA HEMOLYTIC STREPTOCOCCI IN PATIENTS WITH ACUTE EXUDATIVE TONSILITIS IN ISTANBUL, A 14-YEAR PERIOD

Background: Empiric antibiotic therapy is still habitually prescribed to patients with acute exudative tonsillitis in many out-patient clinics in Turkey, despite many studies worldwide showed low group A beta hemolytic streptococci (GABHS) and high viral infection incidence in those patients. In this study, we tried to show the real frequency of GABHS in acute exudative tonsillitis in Istanbul over a 14-year period. Methods: In this retrospective study, we looked through the patient files with acute exudative tonsillitis who had admitted internal medicine and ear-nose-throat out-patient clinics of our hospital in Istanbul, Turkey between 2000 and 2014. We included all patients with the diagnosis of exudative tonsillitis who had a throat swap and culture. We obtained data from the results of throat swab cultures for GABHS. Demographic data and microbiological results were analyzed. Results: Results of throat swab cultures of 967 patients were enrolled in this study (525 male, 442 female; mean age 21±7 years; range 14 to 70 years). In our retrospective analysis GABHS was isolated in only 105 (10.8%) of all patients. Of those patients in whom GABHS were isolated, 56 (5.7%) were male and 49 (5.06%) were female. There was no significant difference between men and women with respect to infection rate (p>0.05). Conclusion: The incidence of GABHS was also low in acute exudative tonsillitis in Istanbul over a 14-year period. Acute exudative tonsillitis was caused by GABHS in only about 10% of all our patients. Tests such as throat culture and rapid antigen test must be performed as soon as possible to confirm diagnosis when there is a suspicion of GABHS infection but routine or immediate antibiotic therapy for acute exudative tonsillitis in adults is not necessary. Key Words: group A beta-hemolytic streptococci; incidence; exudative tonsillitis

Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin

Amoxicillin for the secondary prevention of rheumatic fever in children not allergic to penicillin To the Editor: In October 2014, a communication from the Department of Health substituted azithromycin for erythromycin for penicillin-allergic patients. This was for certain conditions including acute rheumatic fever and prophylaxis of rheumatic fever. It has recently been suggested that owing to the challenges with the availability of oral penicillin, azithromycin should be used as a penicillin substitute for patients who are not allergic to penicillin. In our opinion it is inappropriate to substitute a macrolide for another form of penicillin (amoxicillin) in this situation. The primary reason is that despite many decades of use, there is no significant group A beta-haemolytic streptococcal (GABHS) resistance to penicillin. There are, however, increasing reports of GABHS resistance to macrolides, and azithromycin in particular.[1-4] A previously reported randomised trial[5] of 125 mg phenoxymethylpenicillin (pen VK) or amoxicillin given three times a day for 10 days to children with GABHS pharyngitis demonstrated that the recurrence of the original GABHS within 21 days after the end of therapy was higher with pen VK (20%) than with amoxicillin (13%). The geometric mean minimum inhibitory concentrations for amoxicillin and pen VK against 88 isolates of GABHS were 0.008 and 0.009 μg/mL, respectively. The mean concentrations of amoxicillin and pen VK in sera after 125 mg doses were 3.86 μg/ mL and 1.74 μg/ mL, respectively. In this study, therefore, amoxicillin was active against Gram-positive organisms at an inhibitory level similar to that of pen VK, but had higher blood levels. This study suggests that amoxicillin is probably at least as good as pen VK for the treatment of GABHS pharyngitis. We therefore recommend, as per the South African Essential Drugs List, benzathine penicillin 600 000 units for children <30 kg and 1.2 million units for children ≥30 kg by intramuscular injection every 28 days for the secondary prevention of rheumatic fever. If it is not advisable to use an intramuscular form of penicillin (for example with a patient on warfarin), then in the absence of pen VK and in the absence of penicillin allergy, children weighing <20 kg should be given amoxicillin 125 mg twice daily, and children weighing ≥20 kg given 250 mg twice daily. There is no defined azithromycin paediatric dosage for the secondary prevention of rheumatic fever in penicillin allergy. Azithromycin has however been dosed long term in clinical trials in children with cystic fibrosis.[6-8] There is no consensus on the dosage, but there is some support[6-9] for 250 mg once daily (<40 kg) or 500 mg once daily (≥40 kg) three times a week (Monday, Wednesday and Friday). We recommend that azithromycin is used for the secondary prevention of rheumatic fever only in children who are allergic to penicillin and is dosed 250 mg (<40 kg) or 500 mg (≥40 kg), once a day three times a week (Monday, Wednesday and Friday).

Cervical lymphadenopathies in children: A prospective clinical cohort study

AimCervical lymphadenopathy (LAP) is a common sign and may raise fears about serious illnesses. The aim of our study was to evaluate the patients with cervical LAPs in a general pediatrics clinic setting, and to evaluate follow-up results for potential causes and risk factors for malignancies. Material and methodsTwo hundred-eighteen patients aged between 79.4±46.7 months with LAP were enrolled in this prospective cohort study. The patients were examined in terms of demographics, clinical, radiologic and serologic aspects like Epstein–Barr virus (EBV), cytomegalovirus (CMV), parvovirus B19. A lymph node biopsy was performed in selected patients. The patients were followed-up for 8 weeks and risk factors for malignancy were evaluated. ResultsSeventy patients (41.3%) had specific etiology and 6 (2.7%) had malignant causes. The causes were as follows: 27% (n=59) infections; 2.7% (n=6) malignancies; 11.4% (n=25) other causes. EBV was responsible for 27% of infectious causes. The other common infectious etiologies were CMV 4.3%, parvovirus B-19 2.9%, and group-A beta-hemolytic streptococcus (GAS) 10.8%. Four of the six malignancies were lymphomas. Predictive factors for malignancy were having LAP larger than 30mm, rubbery lymph node, high serum CRP and LDH values, no hilum in ultrasonography, and enlargement of lymph node in follow-up. High uric acid levels and leucopenia were also common in the malignancy group. ConclusionEtiology of cervical LAPs was diagnosed in 41.3% patients. Infectious causes were the most common cause with 27%. Malignancy was diagnosed in 2.7% and lymphoma was the most common malignancy.

Acute exudative tonsillitis in adults: the use of the Centor scoreand some laboratory tests

The aim of our study was to determine the usefulness of the Centor score and some basic laboratory tests (complete blood count and C-reactive protein) for the differential diagnosis of exudative tonsillitis due to Group A &beta;-hemolytic streptococcus (GABHS) or due to non-GABHS agents. The data of clinical and laboratory characteristics of the patients diagnosed with exudative tonsillitis were collected and statistically compared between those having positive GABHS throat culture result and those who were negative for any bacterial agent. Totally 899 adult patients were included in our study; 56 (6.2%) of them were positive for GABHS, while 34 (3.8%) of the cases had a bacterial cause other than GABHS. The remaining 809 (90%) were accepted as non-GABHS cases. The percentages of patients having Centor score of 3 or greater, neutrophilia, lymphocytopenia, and CRP values of greater than 5-fold normal upper reference range were significantly higher in GABHS patients. Centor score of 3 or more together with high CRP, neutrophilia, and lymphocytopenia is predictive for GABHS tonsillopharyngitis.

Reduction of group A beta-hemolytic streptococcus pharyngo-tonsillar infections associated with use of the oral probiotic Streptococcus salivarius K12: a retrospective observational study.

Recurrent pharyngo-tonsillar infections caused by group A beta-hemolytic streptococci (GABHS) occur frequently in young children, and the treatment of these infections contributes substantially to the total current requirement for antibiotic prescribing. Our study goal was to assess through a retrospective observational analysis whether the administration of the oral probiotic, Streptococcus salivarius K12 (SsK12), could reduce the occurrence of GABHS pharyngo-tonsillar infections in children who had a recent history of recurrent episodes of these infections. Twelve primary care pediatricians identified, through their databases, a total of 130 children who had experienced recurrent GABHS pharyngo-tonsillar infections over a period of at least 6–12 months prior to their inclusion in the study. Of these children, 76 then undertook a 90-day program requiring once-a-day dosing with a commercially available (Bactoblis) lozenge containing SsK12. No probiotic supplement was given to the remaining 54 (control) children. Each subject was monitored for the occurrence of GABHS pharyngo-tonsillitis and also for acute otitis media, bronchitis, sinusitis, and bronchopneumonia for at least 12 months following their entry to the study. Even 9 months after the use of SsK12 had been stopped, the probability of new GABHS infections was significantly lower (P>0.001) when compared to the period before dosing commenced. When compared to the untreated children, those taking SsK12 appear to have had significantly fewer GABHS infections both during the 90-day period of prophylaxis and during the following 9 months (P<0.001). These observations are supportive of the use of probiotic SsK12 for the control of recurrent GABHS pharyngo-tonsillar infections in children, and as an associated benefit, the use of this probiotic could lead to reduced antibiotic consumption. Follow-up controlled prospective studies should now be initiated in order to further establish the efficacy of this newly emerging prophylactic strategy.

Prevalence of Beta-Hemolytic Streptococci Groups A, C, and G in Patients with Acute Pharyngitis.

Context:Group A beta-hemolytic streptococci (GAS) is the most frequently isolated pathogen in acute pharyngitis. However, the role of Group C (GCS) and Group G (GGS) streptococci in disease burden is under recognized. The present study is carried out to find out the prevalence of acute pharyngitis caused by the different serogroups of streptococci and antibiotic susceptibility pattern of these streptococcal isolates.Study and Design:A cross sectional study.Materials and Methods:A total of 218 throat swabs from patients with acute pharyngitis and 82 from healthy controls were collected and processed as per standard protocol. Samples were inoculated on blood agar and Streptococcus selective agar. Isolates were identified by the conventional method and serogrouped by latex agglutination test using Remel Streptex kit.Results:Beta-hemolytic streptococci (BHS) were isolated from 34 (15.59%) of pharyngitis patients and 11 (13.41%) of the healthy carrier. Among pharyngitis, GAS was isolated from 20 (9.17%), GCS 7 (3.21%), and GGS 7 (3.21%) patients. Carriage rate of GAS was 6 (7.31%) and GCS, 5 (6.09%). Vancomycin (100%), amoxyclavulanic acid (90%), levofloxacin (85%), and cephotaxime (80%) were found to be most effective antibiotics. Comparatively, higher drug resistance was observed among GCS and GGS to all the drugs used in the study except for levofloxacin.Conclusions:Although rate of pharyngitis associated with GCS and GGS is marginally lower than GAS, their carriage rate among healthy and relative higher drug resistance emphasizes the need for periodic surveillance of infection by the different serogroups of BHS.

A Review-Pandas

PANDAS is hypothesized to be an autoimmune condition in which the body's own antibodies to streptococci attack the basal ganglion cells of the brain, by a concept known as molecular mimicry. PANDAS describes a hypothesis that there exists a subset of children with rapid onset of obsessive-compulsive disorder (OCD) or tic disorders and these symptoms are caused by group A beta-hemolytic streptococcal (GABHS) infections. PANDAS is hypothesized to be an autoimmune disorder that results in a variable combination of tics, obsessions, compulsions, and other symptoms that may be severe enough to qualify for diagnoses such as chronic tic disorder, OCD, and Tourette syndrome. PANDAS is thought to involve autoimmunity to the brain's basal ganglia. children may have other symptoms associated with exacerbations such as emotional liability, enuresis, anxiety, and deterioration in handwriting. five diagnostic criteria were proposed for PANDAS. Concerns have been raised that PANDAS may be over diagnosed, as a significant number of patients diagnosed with PANDAS by community physicians did not meet the criteria when examined by specialists, suggesting the PANDAS diagnosis is conferred by community physicians without conclusive evidence. Treatment for children

COINFECŢIA AMIGDALIANĂ VIRALĂ ŞI BACTERIANĂ. PREZENTARE DE CAZ

Acute tonsillitis is an infection of the tonsils caused by one or more types of bacteria or viruses. We describe a case of acute tonsillitis, in a 8 year-old girl, with beta-hemolytic streptococcus group A, in pharyngeal exudate and staphylococcal methicillin-sensitive nasal swab, together with Epstein-Barr virus’ IgM antibodies. The incidence of infectious mononucleosis concomitant with angina group A beta-hemolytic streptococcal (GABHS) and methicillin sensitive Staphylococcus aureus is much lower, but not exceptional, representing complications of infectious mononucleosis. Amazing is the association of these bacteria in the infectious mononucleosis. Therefore, we face with a possible initial viral infection with secondary bacterial superinfection. In cases like this, a joint venture of the two bacterial infections, antibiotic treatment is recommended in order to prevent complications, especially those that can occur after an untreated strep infection.