Group A Beta-hemolytic Streptococci Research Articles

Patient-clinician agreement on signs and symptoms of 'strep throat': a MetroNet study

Despite substantial use of the telephone in health care, only a few studies have formally evaluated the appropriateness of telephone-based management for acute medical problems. The accuracy of patients' report of signs and symptoms remains unknown. We compared the agreement between patient self-assessment and clinician assessment on the typical signs and symptoms of group A beta-haemolytic Streptococcus (GABHS) to investigate the potential difficulties of using patient self-report to triage sore throat patients. In this cross-sectional study, each of 200 adult pharyngitis patients was instructed to examine him/herself and to record the symptoms and physical findings. Two clinicians independently interviewed and examined each patient and recorded their findings. Each patient then had a rapid GABHS antigen test, the results of which were blinded to both clinicians and patients. Each patient self-assessment was compared with the findings of each clinician, and the agreement and disagreement between them computed. We found varying levels of agreement (kappa=-0.05 to 0.71) between patients and clinicians on sore throat history and physical assessments. Importantly, there was fair to substantial agreement (kappa=0.20-0.71) on the key signs and symptoms used in GABHS clinical prediction rules. As expected, history items had the highest agreement (kappa=0.52-0.71). Patients were more likely than clinicians to report rather than deny a specific physical sign. Adult sore throat patients may reliably report their symptoms, but may not be able to assess and report accurately on relevant physical signs of pharyngitis. Patients have a tendency to over-report physical signs. This study indicates the potential difficulties associated with telephone triage of sore throat patients, or other illnesses that require assessment of physical signs.

The importance of serum creatine phosphokinase level in the early diagnosis and microbiological evaluation of necrotizing fasciitis.

Necrotizing fasciitis (NF) due to group A beta-haemolytic streptococci (GAS) is a rare but still life-threatening soft-tissue infection characterized by rapidly spreading necrosis of the muscle fascia and of the surrounding tissues. NF other than that due to GAS involves the participation of one or more anaerobes and/or of non-group A streptococci, Staphylococcus aureus, enteric organisms, and may be associated with a better outcome. Early diagnosis and treatment, consisting of surgical debridement along with appropriate antibiotic therapy, are required to reduce morbidity and mortality rates. The aim of the study was to analyse the clinical and laboratory findings of patients with GAS NF and with non-GAS NF, and to identify which characteristics could help to diagnose NF in the early stages of infection. We retrospectively analysed the clinical and laboratory findings of 43 cases of GAS and non-GAS NF that occurred in Belgium (n = 32) and at Saga Medical School (Japan) (n = 11) between May 1984 and December 2001. GAS NF more frequently occurred in previously healthy individuals than NF due to other pathogens (P < 0.05) but was associated with a poorer prognosis. Both for patients with GAS NF and with non-GAS NF, the first clinical manifestations often suggested a diagnosis of erysipelas or cellulitis and rarely evoked the correct diagnosis (12% and 15% of the cases, respectively). However, we found that creatine phosphokinase (CPK) values were far higher in patients with GAS NF than in those with non-GAS NF. Our data suggest that GAS may exert particular tropism and/or toxicity for muscle, responsible for early muscle necrosis. This indicates that elevated levels of CPK in a patient with erysipelas or cellulitis-like symptoms should clearly prompt the clinician to exclude the diagnosis of GAS NF.

Group A β-hemolytic streptococcal pharyngitis in children

Group A beta-hemolytic streptococcus (GABHS) is the most common bacterial cause of acute pharyngitis in children. Because clinical findings can be nonspecific, even experienced physicians cannot reliably diagnose GABHS pharyngitis solely on the basis of clinical presentation. Suspected cases should be confirmed by a throat culture or a rapid antigen detection test before antibiotic therapy is initiated. Microbiologic testing is generally not necessary in patients with pharyngitis whose clinical and epidemiologic findings are not suggestive of GABHS. Clinical score systems have been developed to help physicians decide which patients should undergo diagnostic testing and to reduce the unnecessary use of antibiotics. Antibiotic therapy should be initiated as soon as the diagnosis is confirmed. Penicillin V remains the drug of choice. Alternative therapy, e.g., with cephalosporin or macrolide, is often sought because of penicillin allergy, noncompliance, and treatment failure.

Synthesis of group A streptococcal virulence factors is controlled by a regulatory RNA molecule.

The capacity of pathogens to cause disease depends strictly on the regulated expression of their virulence factors. In this study, we demonstrate that the untranslated mRNA of the recently described streptococcal pleiotropic effect locus (pel), which incidentally contains sagA, the structural gene for streptolysin S, is an effector of virulence factor expression in group A beta-haemolytic streptococci (GAS). Our data suggest that the regulation by pel RNA occurs at both transcriptional (e.g. emm, sic, nga) and post-transcriptional (e.g. SpeB) levels. We could exclude the possibility that the pel phenotype was linked to a polar effect on downstream genes (sagB-I). Remarkably, the RNA effector is regulated in a growth phase-dependent fashion and we provide evidence that pel RNA expression is induced by conditioned media.

A possible association of recurrent streptococcal infections and acute onset of obsessive-compulsive disorder.

Rheumatic fever is an immunologically mediated disease that follows infection by group A beta-hemolytic Streptococcus (GABHS). In rheumatic fever, antibodies generated against GABHS cross-react with the heart, joints, skin, and other sites, inducing an inflammatory, multisystem disease. Brain tissue-specific antibodies have been demonstrated in a subset of children with Sydenham chorea (a component of the Jones criteria for the diagnosis of rheumatic fever), and most Sydenham chorea patients manifest obsessive-compulsive symptoms very similar to those in traditional obsessive-compulsive disorder. The parallels drawn from the paradigm of Sydenham's chorea to Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) is an area of active controversy. Newly emerging information on the role of GABHS superantigens in the pathogenesis of rheumatic fever is of particular interest. In this article, we review the microbial characteristics of GABHS and the subsequent immune responses to GABHS as a possible etiology of PANDAS.

PANDAS: current status and directions for research.

The recognition of the five criteria for PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) by Swedo et al established a homogenous subgroup of children with childhood onset obsessive-compulsive disorder (OCD) and/or tic disorders. The five clinical characteristics that define the PANDAS subgroup are the presence of OCD and/or tic disorder, prepubertal age of onset, abrupt onset and relapsing-remitting symptom course, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and a temporal association between symptom exacerbations and a Group-A beta-hemolytic streptococcal (GAS) infection. These five criteria have been used for the purpose of systematic research on the phenomenology and unique therapies for the PANDAS subgroup as well as studies of the pathophysiology of post-streptococcal OCD and tic disorders. The etiology of OCD and tics in the PANDAS subgroup is unknown, but is theorized to occur as a result of post-streptococcal autoimmunity in a manner similar to that of Sydenham's chorea. The working hypothesis for the pathophysiology begins with a GAS infection in a susceptible host that incites the production of antibodies to GAS that crossreact with the cellular components of the basal ganglia, particularly in the caudate nucleus and putamen. The obsessions, compulsions, tics, and other neuropsychiatric symptoms seen in these children are postulated to arise from an interaction of these antibodies with neurons of the basal ganglia.

Rapid diagnosis of pharyngitis caused by group A streptococci.

Although commercial rapid antigen detection tests (RADTs) are more expensive than blood agar plate (BAP) cultures, the advantage they offer is the speed with which they provide results. Rapid identification and consequent prompt treatment of patients with pharyngitis due to group A beta-hemolytic streptococci (GABHS) can reduce the risk of spread of GABHS, can allow patients to return to school or work sooner, and may reduce the acute morbidity of this illness. In most studies, RADTs have been compared with BAP cultures as the criterion standard. However, these comparisons are complicated by the fact that there is no universally accepted procedure for performing a BAP culture. The great majority of the RADTs that are currently available have a high specificity (i.e., 95% or greater) and a sensitivity of between 70 and 90% compared with BAP cultures. Few published studies have compared the performance of various RADTs to each other or examined the performance of various RADTs in the office setting. There is also relatively little published information about how physicians in practice actually use RADTs, but the available information suggests that many physicians do not follow recommended guidelines. While the development of easy-to-perform RADTs for the diagnosis of GABHS pharyngitis has altered clinical practice substantially, only limited data about cost-effectiveness are currently available.

Sensibilité actuelle en France de Streptococcus pyogenes responsable d’angine aiguë

Current guidelines recommend that only tonsillopharyngitis due to group A beta-haemolytic streptococcus (GABHS) diagnosed by rapid diagnostic test should be treated with antibiotics. Empirical antibiotic therapy must be based on epidemiological surveillance of resistance of GABHS to antibiotics. The aim of our study was to assess the activity of antimicrobial agents currently recommended for the treatment of GABHS tonsillopharyngitis. Method The activity of penicillin G, amoxicillin, cefaclor, cefpodoxime, cefuroxime, erythromycin, clarithromycin and clindamycin was determined against 93 consecutive GABHS isolates collected in 2002. MIC50 and MIC90 of antibiotics tested were determined by agar dilution method according to CA-SFM guidelines. Macrolide resistance genes (ermA, ermB, mef) were detected by PCR. Genetic diversity of erythromycin-resistant isolates was analysed by pulsotypic method after digestion by SmaI (Finger-printing II, Biorad). The activity of beta-lactam agents tested was similar and no resistant strain was detected (0%). Nevertheless, this study shows an increasing emergence of erythromycin-resistant GABHS strains reaching 14% in 2002 (vs. 6.2% in a previous study carried out in 1996-1999). The empirical antibiotic therapy of tonsillopharyngitis must consider, on the one hand, the high risk of GABHS eradication failure associated with in vitro resistance to erythromycin and clarithromycin, and on the other hand, the sustained susceptibility of GABHS to beta-lactam agents. These results reinforce the recommendations to use beta-lactam agents as first line treatment of GABHS tonsillopharyngitis.

Pharyngitis clinical prediction rules: effect of interobserver agreement: A MetroNet study

Objective Pharyngitis clinical prediction rules improve Group A beta-hemolytic streptococcus (GABHS) diagnosis and decrease unnecessary antibiotic use, yet few studies have addressed clinician variability in assessment of sore throat signs and symptoms. Study design and setting We conducted a cross-sectional study in which two clinicians examined each of 200 adult sore throat patients. Each patient had a rapid GABHS antigen test. Clinicians were blinded to each other's assessment and to the rapid antigen result. Interobserver agreement was estimated using a kappa coefficient. Effect of agreement on sensitivity, specificity, and hypothetic rapid antigen testing and antibiotic prescribing was determined for two clinical prediction rules. Results We found moderate inter-rater reliability on sore throat history and physical assessments. Clinician agreement was associated with significantly fewer hypothetic rapid antigen tests performed. Conclusion Interobserver agreement enhances the utility of pharyngitis clinical prediction rules. Medical school and residency training should focus on correct assessment of history and physical examination components used in GABHS clinical prediction rules. Correct assessment will result in less GABHS testing and antibiotic prescriptions for sore throat patients.

Detection of Group A beta-hemolytic Streptococcus employing three different detection methods: culture, rapid antigen detecting test, and molecular assay.

In order to study the prevalence of Group A beta-hemolytic Streptococcus (GABHS) pharyngotonsillitis in our pediatric population and to compare different sampling methods of GABHS detection, oropharyngeal swabs from 50 children with acute pharyngotonsillitis, between 1 and 12 years old, were used simultaneously for culture, molecular assay and rapid GABHS antigen detection tests. All children were clinically examined at the Division of Pediatric Otorhinolaryngology of the Federal University of São Paulo. Diagnostic criteria were based on signs and symptoms, including sore throat, fever and oropharyngeal purulent secretion. Children that had been treated with antibiotics were excluded. Overall, combining the three methods, the prevalence of GABHS was 34%. GABHS was diagnosed in 30% of the bacterial cultures, in 25% of the samples tested with the molecular nucleic acid hybridization method and in 26% of the cases tested with the rapid antigen detection test. There was no significant difference between these three methods.

Diagnosis and management of adults with pharyngitis. A cost-effectiveness analysis.

Rheumatic fever has become uncommon in the United States while rapid diagnostic test technology for streptococcal antigens has improved. However, little is known about the effectiveness or cost-effectiveness of various strategies for managing pharyngitis caused by group A beta-hemolytic streptococcus (GAS) in U.S. adults. To examine the cost-effectiveness of several diagnostic and management strategies for patients with suspected GAS pharyngitis. Cost-effectiveness analysis. Published literature, including systematic reviews where possible. When costs were not available in the literature, we estimated them from our institution and Medicare charges. Adults in the general U.S. population. 1 year. Societal. Five strategies for the management of adult patients with pharyngitis: 1) observation without testing or treatment, 2) empirical treatment with penicillin, 3) throat culture using a two-plate selective culture technique, 4) optical immunoassay (OIA) followed by culture to confirm negative OIA test results, or 5) OIA alone. Cost per lost quality-adjusted life-days (converted to life-years where appropriate) and incremental cost-effectiveness. Empirical treatment was the least effective strategy at a GAS pharyngitis prevalence of 10% (resulting in 0.41 lost quality-adjusted life-day). Although the other four strategies had similar effectiveness (all resulted in about 0.27 lost quality-adjusted life-day), culture was the least expensive strategy. Results were sensitive to the prevalence of GAS pharyngitis: OIA followed by culture was most effective when GAS pharyngitis prevalence was greater than 20%. Observation was least expensive when prevalence was less than 6%, and empirical treatment was least expensive when prevalence was greater than 71%. The effectiveness of strategies was also very sensitive to the probability of anaphylaxis: When the probability of anaphylaxis was about half the baseline probability, OIA/culture was most effective; when the probability was 1.6 times that of baseline, observation was most effective. Only at an OIA cost less than half of baseline did the OIA alone strategy become less expensive than culture. Results were not sensitive to other variations in probabilities or costs of diagnosis or treatment of GAS pharyngitis. Observation, culture, and two rapid antigen test strategies for diagnostic testing and treatment of suspected GAS pharyngitis in adults have very similar effectiveness and costs, although culture is the least expensive and most effective strategy when the GAS pharyngitis prevalence is 10%. Empirical treatment was not the most effective or least expensive strategy at any prevalence of GAS pharyngitis in adults, although it may be reasonable for individual patients at very high risk for GAS pharyngitis as assessed by a clinical decision rule.

Group A beta-hemolytic streptococcal osteomyelitis in children.

Little attention has been given to acute hematogenous osteomyelitis (AHO) caused by group A beta-hemolytic Streptococcus (GABHS), although up to 10% of cases are caused by this microorganism. The objective of this study was to define the clinical and laboratory characteristics of AHO caused by GABHS. Between January 1983 and June 1999, 29 patients were treated at Children's National Medical Center with AHO caused by GABHS. The characteristics of these patients were compared with those of 28 patients with AHO caused by Streptococcus pneumoniae and those of a matched sample of 45 patients with AHO caused by Staphylococcus aureus. Median ages of children with GABHS, S pneumoniae, and S aureus AHO were 36.0, 13.7, and 96.0 months, respectively. On admission, patients with GABHS AHO had a mean temperature of 38.9 +/- 1.3 degrees C and a mean white blood cell count of 17 000 +/- 7800/mm3, findings similar to those from patients with S pneumoniae AHO. Patients with S aureus AHO had significantly lower admission temperature (38.1 +/- 1.1 degrees C) and white blood cell count (10 600 +/- 4900/mm3). Varicella infection was the risk factor in 5 cases (17%) of GABHS AHO, whereas none of the cases of AHO caused by S pneumoniae and S aureus was associated with varicella infection. Adjacent septic arthritis occurred in 22%, 28%, and 61% of children with GABHS, S aureus, and S pneumoniae AHO, respectively. Admission erythrocyte sedimentation rate and frequency of bacteremia were similar in all groups. However, time to normalization of erythrocyte sedimentation rate was longer for GABHS and S aureus than for S pneumoniae AHO. GABHS, like S pneumoniae, affected fewer nonextremity bones compared with S aureus. GABHS should be considered in preschool- and early school-aged children who are suspected of having AHO and whose clinical and laboratory features are characterized by high fever and marked leukocytosis. It should also be highly considered in any child with AHO associated with varicella infection.

Rapid test, throat culture and clinical assessment in the diagnosis of tonsillitis.

Our aim was to identify a group of patients with clinical signs of tonsillitis to whom antibiotics could be prescribed without further diagnostic actions, and to compare the outcome of clinical assessment with the result of an antigen detection test using culture as the gold standard. During two winter months, patients aged > or =4 years attending for sore throat at three primary health care centres in Malmö, Sweden, were examined. Odds ratios, sensitivities, specificities and predictive values were calculated for clinical assessment and for an antigen detection test. Among the 169 participating patients, growth of group A beta-haemolytic streptococci (GAS) was found in 53 cultures, and 23 patients (14%) were clinically assessed as 'absolutely positive', representing positive clinical assessment. Nineteen had positive cultures for GAS. The sensitivity, specificity and predictive positive and negative value for the antigen detection test were 82, 96, 90 and 93%, respectively, and for positive clinical assessment 36, 97, 83 and 77%. It is possible to identify a small group of patients with convincing signs of tonsillitis in which the specificity as well as the predictive positive value of the rapid test and the clinical assessment are close to equal. Antibiotics may be prescribed to these patients without further diagnostic actions.

PREVALENCE OF STREPTOCOCCAL PHARYNGITIS AMONG SCHOOL CHILDREN OF POKHARA VALLEY, NEPAL

Group A Beta Haemolytic Streptococcal (GABHS) infections and their sequelaeRheumatic fever (RF) and Glomerulonephritis (GN) have a world wide distributionand pose an important health problem. Present study intended to find out the prevalenceofGABHS pharyngitis among school children in the Pokhara Valley, Nepal. It was across sectional, observational study. During 7 months period total 750 children wereexamined from six government primary schools. 25.3% were found to have symptomsof clinical pharyngitis and the prevalence of GABHS pharyngitis was 7.2% amongthese school children. GABHS pharyngitis found more among male and in the agegroup of 3-10 years. This study was undertaken to highlight the problems of GABHSthroat infections in Nepalese school children and also to stress on the urgent need forcontrol programme for streptococcal disease complex.Key Words: Prevalence, Streptococcal pharyngitis, School children.

Comparison of 5 days of extended-release clarithromycin versus 10 days of penicillin V for the treatment of streptococcal pharyngitis/tonsillitis: results of a multicenter, double-blind, randomized study in adolescent and adult patients

SUMMARYObjective: This study compared a short-course of clarithromycin with a standard course of penicillin V in patients with tonsillopharyngitis caused by Streptococcus pyogenes.Research design and methods: A total of 539 patients, aged 12–75 years, were randomized to receive either clarithromycin extended-release (ER) 500 mg once daily for 5 days or penicillin V 500 mg three times daily for 10 days in this multicenter, double-blind, parallel-group trial. Eligibility required a positive antigen test for group A beta-hemolytic streptococcus (GABHS) followed by confirmatory culture.Main outcome measures: Bacteriological and clinical assessments were conducted at each study visit (visit 1: study day 1; visit 2: study day 3; visit 3: study days 8–12; visit 4: study days 13–20; and visit 5: study days 40–50).Results: At the test-of-cure visit (visit 3 for clarithromycin ER patients and visit 4 for penicillin V patients) in per-protocol patients, 5 days of clarithromycin ER was comparable to 10 days of penicillin V in eradicating S. pyogenes (89% (157/177) vs 90% (139/154) respectively; 95% CI for difference (−8.2, 5.1)). Bacterial eradication was sustained in both treatment groups at the follow-up visit (88% (135/153) vs 91% (112/123) respectively; 95% CI for difference (−10.0, 4.4)). Clinical cure was achieved in > 94% of patients in each treatment group. The most commonly reported study drug-related adverse events (< 3% in either treatment group) were abdominal pain, diarrhea, dyspepsia and nausea.Conclusion: Clarithromycin ER 500 mg once daily for 5 days is equally effective as penicillin V 500 mg three times daily for 10 days in the treatment of adolescent and adult patients with streptococcal tonsillopharyngitis.

Perineal streptococcal dermatitis/disease: recognition and management.

Perianal streptococcal dermatitis (PSD) is a pediatric dermatologic infectious disease predominantly affecting children, particularly younger children, which is most commonly caused by group A beta-hemolytic streptococci (GABHS). Although the clinical picture of a sharply demarcated erythema is very characteristic, PSD is often misdiagnosed for long periods of time and patients are subjected to treatments for a variety of differential diagnoses. Vulvar and penile involvement with similar signs and symptoms have been documented in several patients with PSD. The diagnosis is made by either a swab of the affected region submitted for microbiological analysis with the specific question for GABHS, or a rapid strep test. Systemic antibiotics such as penicillin, erythromycin, newer macrolides, or others, probably augmented by topical antiseptic or antibiotic ointments are the treatment of choice. Treatment duration should be at least 14 days or, even better, 21 days, and be dictated by clinical and microbiological cure. Therefore treatment success should be investigated not only by clinical examination but also by post-treatment perineal swabs as well as a urine analysis to monitor for post-streptococcal glomerulonephritis. The author of this review supports the recent suggestion to summarize GABHS-induced vulvovaginal and penile infections together with PSD under the inclusive term 'perineal streptococcal disease' because these conditions coincide, share important clinical characteristics and, therefore, represent manifestations of the same disease.

Group A streptococcal pharyngitis

Acute pharyngitis is a common illness in both children and adults, caused by a wide variety of microbial agents. In children, approximately 20% of pharyngitis is caused by group A beta-hemolytic streptococci (GABHS); in adults, 5% of pharyngitis is due to GABHS. The signs and symptoms of infection are variable, ranging from mild sore throat with minimal physical findings to high fever and severe pain. The differential diagnosis of GABHS pharyngitis is extensive. Most cases of acute pharyngitis in both children and adults are caused by viruses. The gold standard diagnostic test for GABHS remains the throat culture. It is important to select appropriate candidates for culture to maintain the sensitivity of the test. Penicillin is still recommended as first-line treatment for documented GABHS infections. Prompt treatment is important to prevent serious sequelae of infection.

Identification of Clinical Criteria for Group A- Hemolytic Streptococcal Pharyngitis in Children Living in a Rheumatic Fever Endemic Area

A cross-sectional study was conducted over a 1-year period (1 January-31 December 2000) during which cases suffering from uncomplicated tonsillopharyngitis were recruited from the private and public health services in Alexandria. The objective was to determine the prevalence of group A-beta haemolytic streptococci (GABHS) among children suffering from tonsillopharyngitis and to identify the clinical criteria predicting GABHS pharyngitis in children. A total of 578 children aged between 1 and 15 years with a mean of 6.3 +/- 3.7 years, presenting with sore throat were enrolled in the study. Demographic data and presenting signs and symptoms for each patient were recorded on a standardized form and a throat swab was taken using the filter paper technique. The overall prevalence of GABHS was 17 per cent and the highest isolation rate was reported in children aged 10-15 years. Non-GABHS comprised 11.9 per cent of the total isolates. The most prevalent of them were group C and G streptococci. The highest frequency of both GABHS and non-GABHS was in early spring. Significant predictors of GABHS pharyngitis were: age 10-15 years, the presence of dysphagia, vomiting, pharyngeal exudate, and scarlatiniform rash. Watery eyes and/or rhinitis had a protective value against the diagnosis of GABHS pharyngitis, while fever was considered to be a non-specific finding in cases with GABHS pharyngitis. Antibiotic sensitivity test showed higher sensitivity to both penicillin and erythromycin. Only 1 per cent of the GABHS isolates showed resistance to cephadroxil. We concluded that a syndrome of signs and symptoms could be used as a clinical predictor for the diagnosis of GABHS pharyngitis.

Severe group A streptococcal infection and a pulmonary hemorrhage

Group A beta hemolytic streptococcus (GAS) commonly causes pharyngitis. Antibiotics are used to treat these infections to prevent the development of rheumatic fever. A 4-year old male developed multiple organ system failure, including a life-threatening pulmonary hemorrhage. Blood, urine, and throat cultures were positive for GAS.

Clinical score card for diagnosis of group A streptococcal sore throat.

Group A beta hemolytic streptococcus (GAS) sore throat primarily occurs among children in 5-15 years age group, and if not treated appropriately causes rheumatic fever/rheumatic heart disease (RF/RHD). Present study was aimed at validation of a clinical scoring system for diagnosis of GAS. Five hundred and thirty six children in 5-15 years age group were enrolled by systematic random selection of households from a peri-urban slum of Chandigarh. They were visited fortnightly at their home for one year to record signs and symptoms of cough and cold. Throat swabs were collected in 918 episodes, of which 123 (13.4%) were GAS culture positive. Significant association of GAS was found with pain in the throat, enlarged tonsils, pharyngeal erythema and tender cervical lymphadenopathy. According to the percentage positivity of GAS culture, weighted scores were assigned to age of the child, season of occurrence, fever, size of tonsil, pharyngeal erythema and exudate, lymphadenopathy and pain in throat. Combinations of various symptoms and signs gave sensitivity of 86-89% and specificity of 83-89% whereas clinical score of 15 or more had 91% sensitivity and 98% specificity for diagnosis of GAS pharyngitis. As the level of clinical acumen and prevalence of GAS may differ in different primary care settings of the country, the proposed scoring system should be validated and adapted to suit local conditions before establishing it in the primary prophylaxis strategy to prevention of RF/RHD.