Throat Cultures Research Articles

7504 A Case of Methicillin Sensitive Staphylococcus Aureus Thyroiditis

Abstract Disclosure: K. Patel: None. P. Kachhadia: None. S. Khan: None. F. Akanbi: None. A. Abu Limon: None. S.A. Aldasouqi: None. Introduction: Acute suppurative thyroiditis refers to bacterial infection of the thyroid gland. It is rare as the thyroid gland is typically protected from infection due to isolation of the gland from neighboring structures as well as its rich blood supply and adequate lymphatic drainage. It shares characteristics with subacute and autoimmune thyroiditis which make for difficult diagnosis. Here we present a case of acute suppurative thyroiditis in the setting of methicillin sensitive staphylococcus aureus (MSSA) bacteremia. Case Presentation: We have a 45 year old gentleman with a history of polysubstance abuse who was admitted after a drug overdose. He was being treated for rhabdomyolysis and approximately ten days after admission he became febrile with Tmax 103.3 Farenheit with a sore throat and dysphagia. Workup showed leukocytosis, ESR 86 mm/h [0-15], CRP 45.5 mg/dL [0-1], blood cultures with MSSA, negative viral upper respiratory panel, throat culture, Syphilis and HIV testing. He had a positive Hepatitis C antibody without a detectable viral load. Echocardiogram ruled out vegetations. He was treated with cefazolin. CT neck was obtained and showed thyroid enlargement. Subsequent ultrasound showed heterogeneous echotexture and increased color flow and a left inferior pole nodule 2.3 x 2.1 x 2.0 cm. Thyroid labs showed TSH 0.16 [0.35 - 4.01 u[IU]/mL,] Free T4 3.91 ng/dL [0.61 - 1.37], TPO <0.3. The nodule was biopsied and endocrinology was consulted. On exam thyroid was nontender. He was started on beta blockers and thyroid labs were monitored. TSI and TRAB were negative. TSH, Free T4 and Free T3 improved to normal range. Nodule biopsy results showed benign follicular cells with abundant acute inflammation suggestive of an abscess. Metronidazole was added after biopsy results. Post antibiotic therapy, CRP improved to 1.7 mg/dL. Discussion/Conclusion: Incidence of acute suppurative thyroiditis has been published as occurring <1% of all thyroid diseases. One systematic review found 200 cases reported from January 2000 to January 2020. Prior case reports have described acute suppurative thyroiditis in adult patients with prior thyroid gland pathology or an immunocompromised state and some demonstrated a correlation with intravenous drug users. The most common culprits include Staphylococcus spp, Streptococcus spp, Salmonella spp, Escherichia spp. Management includes antimicrobial therapy and/or needle aspiration. Non-responders can undergo incision and drainage of abscess or thyroidectomy. Mortality was reported in about 8% of the reported 200 cases. In our patient, his history of drug use and Hepatitis C likely made him prone to infection. Although there was no description of pus during biopsy, pathology suggested acute inflammation. This along with elevated inflammatory markers led to the diagnosis. This case highlights an uncommon but potential cause of thyroiditis. Presentation: 6/3/2024

6472 Methimazole Induced Agranulocytosis: Uncommon Complication of a Common Medication

Abstract Disclosure: R. Kaur: None. L. Kaur: None. A. Sridhar: None. T. Chaudhary: None. N. Patel: None. Methimazole (MMI) induced agranulocytosis is a rare and life threatening adverse effect that usually occurs within 3 months of drug initiation and can rapidly lead to overwhelming infection. It is reported in 0.1 to 0.5 % of patients on treatment with methimazole. MMI is a standard drug used in graves disease and toxic multinodular goiter. We report a case of MMI induced agranulocytosis in an elderly female with recently diagnosed toxic multinodular goiter. A 66 year old female with past medical history of recently diagnosed toxic multinodular goiter for which she was started on methimazole 80mg/day two months ago presented to the emergency department with chief complaint of severe sore throat associated with rapidly increasing pharyngeal pain and fever over the past 24 hours. She was lethargic, febrile with temperature of 102 F, tachycardic with heart rate of 115/minute and hypotensive with blood pressure of 108/64 mm Hg. Physical examination revealed diffuse pharyngeal and tonsillar erythema with bilateral purulent exudate with tender anterior cervical lymphadenopathy. Thyroid was enlarged, firm, irregular and nontender. Pulmonary, cardiac and abdominal exam was unremarkable. Lab work showed severe leukopenia with WBC count of 1,600/mm3, neutropenia with absolute neutrophil count of 0.0 x 1000/ul (normal range 1.8-7.3 x 1000/ul) and erythrocyte sedimentation rate and C reactive protein were both elevated. Blood cultures and fungal cultures showed no growth. Urinalysis and urine culture were both unremarkable. She had an extensive haematological, rheumatological and infectious disease workup for neutropenia, which was largely unrevealing. Rapid streptococcal testing was negative but throat cultures grew beta haemolytic streptococci. Treatment included suspending methimazole, administering antimicrobial therapy with piperacillin - tazobactam, acyclovir and fluconazole. She was also started on a granulocyte colony stimulating factor. Patient presented satisfactory evolution with progressive increase in leukocyte count and remission of symptoms by day 5 of treatment, rendering further bone marrow testing unnecessary. Antibiotics were changed to oral amoxicillin-clavulanic acid after throat culture results were available and the patient was discharged in stable condition. One month after discharge she underwent total thyroidectomy for definitive cure and is currently followed up as an outpatient by endocrinology. The objective of this case report is to present an uncommon case of agranulocytosis secondary to use of methimazole and to increase awareness among the physicians about the need to consider this diagnosis in patients on this medication. It is also advised that these patients be educated about the drugs side effects, a practice that may avert suffering and unnecessary costs. Presentation: 6/3/2024

The relationship between group A streptococcus test positivity and clinical findings in tonsillopharyngitis in children: systematic review and meta-analysis.

This study aimed to present an evidence-based conclusion through a systematic meta-analysis to distinguish clinical signs and symptoms associated with the presence of group A beta-hemolytic streptococcus, as confirmed by throat culture or rapid test, from those in cases without culture confirmation. The study protocol has been published in PROSPERO (CRD42023450854). Studies published between January 1, 2013 and August 15, 2023 were scanned in seven databases. The methodological quality of the articles was assessed using The Joanna Briggs Institution (JBI) Cross-Sectional Studies and Cohort Studies checklist. Effect size calculations were made using fixed effects and random effects models. A total of 22 articles were included in the systematic review, with 14 included in the meta-analysis. The prevalence of streptococcal pharyngitis in these studies ranged from 7.3 to 44.1%. According to the meta-analysis results, a significant association was observed between GAS test positivity and the presence of tonsillar exudate, palatal petechiae, tonsillar hypertrophy, dysphagia, fever, and cervical lymphadenopathy (p < 0.05). No significant relationship was found between GAS test positivity and symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain (p > 0.05). The findings of the meta-analysis suggest that, in addition to the Centor criteria, palatal petechiae, dysphagia, and tonsillar hypertrophy are noteworthy indicators of GAS infection. Contrary to previous studies, our meta-analysis indicates that symptoms such as headache, sore throat, cough, absence of cough, hoarseness, scarlatiniform rash, tonsillar erythema, vomiting, rhinorrhea, and abdominal pain may not be associated with streptococcal infection. Further research is needed to elucidate these findings.

Membranous tonsillitis: Aetiology, prevalence and prescribing patterns in patients with upper respiratory tract infection.

Background Membranous tonsillitis is one of the most common forms of acute tonsillitis in childhood. Although many different microorganisms may cause this disease, clinicians generally consider bacterial agents as a possible cause and prescribe a penicillin-group of antibiotic. This study aimed to determine the aetiology of membranous tonsillitis and prescribing errors. In addition, we investigated the effectiveness of epidemiological, clinical and laboratory parameters and their role in guiding treatment. Methods We did this retrospective study at the paediatric emergency department of a tertiary referral hospital including 423 outpatient children aged 0 to 18 years diagnosed with membranous tonsillitis. Results Group A beta-haemolytic streptococcus was found in 132 (31.2%) patients, Epstein-Barr virus (EBV) in 103 (24.3%), and other viral aetiologies in 188 (44.4%). The prescription rate of antibiotics in the EBV-positive group was 27%, and Downey cells were seen at a rate of 98% in this group. Only 7% of patients with a positive throat culture were started on appropriate antibiotics. Conclusion EBV and group A beta-haemolytic streptococcus were the most common causes of membranous tonsillitis. Throat culture and peripheral blood smears are the most useful tests for paediatric emergency clinicians; these are fast and can help ensure correct diagnosis and guide treatment in almost all patients.

The Efficacy of Paraprobiotic Lozenges (Lactobacillus helveticus MIMLh5) for the Prevention of Acute and Chronic Nose and Throat Infections in Children.

Background and Objectives: Tonsillitis is common in children and is predominantly caused by viruses and, less frequently, by bacteria such as group A beta-hemolytic streptococcus. The treatment primarily involves supportive care; however, the overuse of antibiotics remains a concern due to rising antibiotic resistance. Probiotics, particularly Lactobacillus strains, have been shown to modulate immune responses, offering a potential alternative treatment. Materials and Methods: Our prospective single-arm, open-label study included 98 pediatric patients aged 5-15 years with recurrent throat and tonsil infections, from October 2022 to January 2023. Patients received lozenges containing heat-killed Lactobacillus helveticus MIMLh5. Monthly follow-ups involved a comprehensive ear, nose, and throat examination, throat cultures, and recording the frequency of infections and antibiotic use. Data were analyzed using SPSS 29.0, with statistical significance set at p < 0.05. Results: After three months, significant reductions were observed in the occurrences of nose and throat infections (p < 0.001), enlarged submandibular glands (p < 0.001), and positive throat cultures (p < 0.001). Antibiotic and corticosteroid prescriptions also significantly decreased (p < 0.001). Among children aged 5-10 years, significant improvements were noted in throat and tonsil infections (p < 0.001) and positive throat cultures (p = 0.012). Overall, there was a substantial reduction in school days missed (p < 0.001). Conclusions: The use of paraprobiotic Lactobacillus helveticus MIMLh5 lozenges significantly reduced the incidence of recurrent throat and tonsil infections in children, decreased the need for antibiotics and corticosteroids, and improved overall clinical outcomes without adverse effects. These findings support the use of paraprobiotic supplements as a safe and effective preventive measure for pediatric throat and tonsil infections.

A highly sensitive 3base™ assay for detecting Streptococcus pyogenes in saliva during controlled human pharyngitis

Streptococcus pyogenes (Group A Streptococcus; GAS) is a Gram-positive bacterium responsible for substantial human mortality and morbidity. Conventional diagnosis of GAS pharyngitis relies on throat swab culture, a low-throughput, slow, and relatively invasive ‘gold standard’. While molecular approaches are becoming increasingly utilized, the potential of saliva as a diagnostic fluid for GAS infection remains largely unexplored. Here, we present a novel, high-throughput, sensitive, and robust speB qPCR assay that reliably detects GAS in saliva using innovative 3base™ technology (Genetic Signatures Limited, Sydney, Australia). The assay has been validated on baseline, acute, and convalescent saliva samples generated from the Controlled Human Infection for Vaccination Against Streptococcus (CHIVAS-M75) trial, in which healthy adult participants were challenged with emm75 GAS. In these well-defined samples, our high-throughput assay outperforms throat culture and conventional qPCR in saliva respectively, affirming the utility of the 3base™ platform, demonstrating the feasibility of saliva as a diagnostic biofluid, and paving the way for the development of novel non-invasive approaches for the detection of GAS and other oropharyngeal pathogens.

Trends in decision-making by primary care physicians regarding common infectious complaints

Background Primary care physicians played an important role in the global response during the COVID-19 pandemic, but with the absence of laboratory and diagnostics services, the move to telehealth and the focus on respiratory assessment, they faced increased uncertainty when making clinical decisions. Objectives This paper aims to examine the impact of the pandemic on decisions made by primary care physicians, as measured by referrals to chest X-ray and laboratory tests and by prescriptions of antibiotics. Methods We conducted a retrospective study of all visits recorded with fever or cough, presenting to 209 community clinics in Southern Israel during the years 2018–2022. We describe changes in outcome rates across time and use multivariate generalised linear mixed effects model to compare the odds of referrals and prescriptions between periods, while accounting for gender, age, clinic sector, visit type, diagnosis, and season. Results In total, 609,823 visits to primary care physicians complied with the cohort definitions. Social restrictions were associated with a decline in all measured outcomes for primary care physician decisions, most prominently among ages 20-59, for throat culture referral during the first lockdown (OR = 0.46) and for cephalosporine prescription during the second lockdown (OR = 0.55). This trend persisted following the cancellation of the restrictions. Conclusions Despite higher uncertainty during the COVID-19 social restrictions, the overall course of clinical decision-making processes was maintained, and was associated with a reduction in the use of auxiliary resources, which can improve the quality of patient care by lowering costs and supporting prevention of future antibiotics resistance.

Impact of Pharmacist Involvement in Post-Discharge Emergency Department Culture Review.

Background: Many infectious diseases are diagnosed in emergency departments (ED) and patients are prescribed antimicrobial therapy. Results from cultures typically take a few days to become finalized. Following up on these results is necessary when medication changes are indicated due to results that show bacteria are resistant to the prescribed antibiotics. Involving pharmacists in assessing the culture and sensitivity results, and making interventions when needed, is an innovative way to ensure that patients receive appropriate antimicrobial therapy based on the culture and sensitivity data. This study analyzed the impact of pharmacist involvement in the ED's post-discharge positive culture review process on ED re-visits and hospitalizations. Methods: This single-center, pre- and post-implementation study examined the impact of pharmacist involvement in the post-ED visit culture review process on ED re-visits and hospitalizations. Positive microbiological results included documented growth from urine, skin and soft tissue, throat, blood, or stool cultures. Patients included in the study were of 18 years of age or older and had a positive culture result post ED-discharge. Patients were excluded from the study if they were admitted to the hospital or transferred to another facility. The primary outcomes included ED re-visits within 7 days and hospital readmissions within 30 days for the same condition. The secondary outcomes were percentage of pharmacist interventions accepted and types of pharmacist interventions implemented. Results: A total of 141 patients were included in the study, with 65 in the pre-implementation group and 76 in the post-implementation group. The primary outcome of ED re-visits within 7 days for the same condition occurred in 11 (17%) patients in the pre-implementation group and 5 (7%) patients in the post-implementation group (P = .0454). The primary outcome of hospitalizations within 30 days for the same condition occurred in 5 (8%) patients in the pre-implementation group and 1 (1%) patient in the post-implementation group (P = .0137). Seventeen (94%) out of the 18 pharmacist interventions were accepted and implemented. The intervention types implemented were to recommend to: change antibiotic (35%), not initiate antibiotic (24%), initiate antibiotic (24%), and continue antibiotic (18%). Conclusion: Pharmacist involvement in the ED post-discharge positive culture review process showed a decrease in ED re-visits and hospitalizations for the same condition.

Molecular Point-of-Care Testing in the Emergency Department for Group A Streptococcus Pharyngitis : A Randomized Trial.

To compare clinical and health systems outcomes of rapid molecular testing versus throat culture recovery for the management of group A Streptococcus (GAS) pharyngitis in a pediatric emergency department (PED). We conducted a single-center randomized trial of children (3-17 years) presenting to a PED with suspected GAS pharyngitis. A single dual-headed throat swab was collected, and participants were randomized to 1 of 2 parallel treatment groups with 1:1 allocation: point-of-care (POC) nucleic acid amplification testing or standard throat culture. The primary outcomes were time to throat pain +/- fever resolution. Secondary outcomes included absenteeism, length of stay, return visits to care, and antibiotic prescriptions and utilization. A total of 227 children were randomly assigned to culture (n = 115) or POC (n = 112) testing. Antibiotics were initiated earlier in the POC group by approximately 1 day (95% confidence interval, -0.40 to -1.58). No associated difference in time to throat pain or fever resolution was observed between groups. There was a decrease in the proportion of prescribed antibiotics in the POC group (0.35) compared with the culture group (0.79; P < 0.001). Otherwise, no significant differences in secondary outcomes were observed. Establishing a POC nucleic acid amplification testing program for GAS in a PED facilitates earlier treatment and fewer antibiotic prescriptions. Although this did not translate to improved clinical and health systems outcomes in our study, it may serve as an important tool amid evolving pediatric febrile illnesses and growing antimicrobial resistance patterns.

Clinical manifestations, diagnosis, and antimicrobial resistance of group A streptococci infections

Group A streptococci (GAS) cause diverse diseases ranging from mild to severe illnesses, and the global burden of GAS infections is enormous. Serological typing has been replaced by emm genotyping for the epidemiological study of GAS. Acute bacterial pharyngitis is a common illness, which requires either throat culture or rapid Ag test for diagnosis. Moreover, molecular point-of-care tests have been introduced owing to their higher sensitivity. Optimal diagnosis of bacterial pharyngitis is necessary for the adequate use of antibiotics. Although antimicrobial resistance (AMR) to erythromycin or clindamycin does not seem serious in Korea, it is very high in China, being reported at over 90%. Antibiotic surveillance and relevant education are necessary for primary clinical physicians and pediatricians. It is necessary to monitor AMR and develop a system for reporting the appearance of highly virulent diseases, such as necrotizing fasciitis or streptococcal toxic-shock syndrome, to the government authority.

Clinico-Bacteriological Evaluation of Surface and Core Tonsillar Tissue in Chronic Tonsillitis

Introduction: Chronic tonsillitis is the most common disease for Otolaryngologists. Effective treatment of tonsillitis depends on knowledge of the infecting organisms. Controversy regarding the treatment of tonsillitis based on throat culture report still persists. There is always a dilemma whether the antibiotics prescribed for tonsillitis are sufficient for the different organisms on the surface and core of the tonsils. If surface culture is a determinant of bacteriology of the core, then rational therapy could be aimed at organisms cultured by surface swabs.&#x0D; Aims: To study the correlation of bacteria isolated from the surface and core of the tonsil in chronic tonsillitis and antibiotic sensitivity of the bacterial isolates.&#x0D; Methods: This was a prospective study carried out on fifty patients, who underwent tonsillectomy for chronic tonsillitis. The swabs obtained from the surface of the tonsil before tonsillectomy and the core of the tonsil post tonsillectomy were sent for isolation of micro-organisms. Antibiotic sensitivity test was performed by Kirby-Bauer Disk Diffusion method on the bacterial isolates.&#x0D; Results: Bacterial growth was detected in 74% of the total sample, in cultures from the surface or the core tissue or both. 78% of surface samples versus 70% of tonsillar core samples revealed bacterial growth. No pathogens were isolated in 26% of samples. Staphylococcus Aureus and Group A β hemolytic streptococcus were the most commonly isolated organisms. Antibiotics sensitive against these pathogens include Amoxycillin-Clavulanic acid, Cefpodoxime, Amikacin, Levofloxacin, Doxycycline, and Nitrofurantoin.&#x0D; Conclusion: Our study shows that surface culture does not reliably predict core pathogens in cases of chronic infection. Staphylococcus Aureus and Group A β hemolytic streptococcus were the most commonly isolated organisms from the surface and core of the tonsil. So the antibiotics effective against these organisms should be chosen.

Serum Immune Responses to Group A Streptococcal Antigens following Pharyngeal Acquisitions among Children in Cape Town, South Africa.

There is limited information on the human immune response following infection with group A Streptococcus (Strep A). Animal studies have shown, in addition to the M protein, that shared Strep A antigens elicit protective immunity. This study aimed to investigate the kinetics of antibody responses against a panel of Strep A antigens in a cohort of school-aged children in Cape Town, South Africa. Participants provided serial throat cultures and serum samples at two-monthly follow-up visits. Strep A recovered were emm-typed, and serum samples were analyzed by enzyme-linked immunosorbent assay (ELISA) to assess immune responses to thirty-five Strep A antigens (10-shared and 25-M peptides). Serologic evaluations were performed on serial serum samples from 42 selected participants (from 256 enrolled) based on the number of follow-up visits, the frequency of visits, and throat culture results. Among these, there were 44 Strep A acquisitions, 36 of which were successfully emm-typed. Participants were grouped into three clinical event groups based on culture results and immune responses. A preceding infection was most convincingly represented by a Strep A-positive culture with an immune response to at least one shared antigen and M peptide (11 events) or a Strep A-negative culture with antibody responses to shared antigens and M peptides (9 events). More than a third of participants demonstrated no immune response despite a positive culture. This study provided important information regarding the complexity and variability of human immune responses following pharyngeal acquisition of Strep A, as well as demonstrating the immunogenicity of Strep A antigens currently under consideration as potential vaccine candidates. IMPORTANCE There is currently limited information regarding the human immune response to group A streptococcal throat infection. An understanding of the kinetics and specificity of antibody responses against a panel of Group A Streptococcus (GAS) antigens will serve to refine diagnostic approaches and contribute to vaccine efforts, which together will serve to reduce the burden of rheumatic heart disease, a major source of morbidity and mortality especially in the developing world. This study, utilizing an antibody-specific assay, uncovered three patterns of response profiles following GAS infection, among 256 children presenting with sore throat to local clinics. Overall, the response profiles were complex and variable. Of note, a preceding infection was most convincingly represented by a GAS-positive culture with an immune response to at least one shared antigen and M peptide. Also, more than a third of participants demonstrated no immune response despite a positive culture. All antigens tested were immunogenic, providing guidance for future vaccine development.

Severe Neonatal Skin Infection: Clinical Case

Background. Pyoderma is the most common skin infectious disease of early age, it is a group of dermatoses characterized by purulent-inflammatory damage to the skin, dermal appendages, and subcutaneous fat. The diagnosis is based on medical history and physical examination. The main treatment methods are antibacterial therapy (local or systemic) and antiseptic skin toilet. Some forms of deep pyoderma require surgical interventions.Clinical case description. Girl A., 14 days of life, was admitted to the neonatal department of infectious disease with complaints of the mass in the left shoulder joint area. Historical information: 27 years old mother was not observed in any maternity welfare centre; chorioamnionitis was revealed at admission to the obstetric hospital. She received broad-spectrum antibacterial therapy perinatally. A girl from spontaneous vaginal delivery born on the 39th week with body weight of 2700 g, body length of 50 cm, and APGAR score of 8/9, she was breastfed. The condition on admission was severe. There were multiple indurated rash elements (pustules with turbid fluid) on the skin of the chest, limbs, and back. Skin desquamation was noted. There was hyperemia area up to 3.5 × 1.5 cm in the left shoulder joint area, with soft-elastic consistency, fluctuation symptom was positive. Complete blood count has shown: leukocytosis and neutrophilosis. Methicillin-resistant Staphylococcus aureus (MRSA) was revealed in blood via PCR method, in hemoculture, and in throat and nose cultures. C-reactive protein level was increased. Abscess culture — MRSA. Screening by immunological assay was performed to exclude primary immunodeficiency. Abscess incision and drainage were performed; 5 mL of thick yellow-green pus was obtained. Combination therapy with broad-spectrum antibiotic was carried out.Conclusion. There was positive dynamics on the administered therapy: the child condition was satisfactory, skin cleared of infectious rash, abscess was sanitized, laboratory parameters normalized, the child had no fever.

Time to negative throat culture following initiation of antibiotics for pharyngeal group A Streptococcus: a systematic review and meta-analysis up to October 2021 to inform public health control measures.

BackgroundPublic health guidance recommending isolation of individuals with group A streptococcal (GAS) infection or carriage for 12-24 h from antibiotic initiation to prevent onward transmission requires a strong evidence base.AimTo estimate the pooled proportion of individuals who remain GAS culture-positive at set intervals after initiation of antibiotics through a systematic literature review (PROSPERO CRD42021290364) and meta-analysis.MethodsWe searched Ovid MEDLINE (1946-), EMBASE (1974-) and Cochrane library. We included interventional or observational studies with ≥ 10 participants reporting rates of GAS throat culture positivity during antibiotic treatment for culture-confirmed GAS pharyngitis, scarlet fever and asymptomatic pharyngeal GAS carriage. We did not apply age, language or geographical restrictions.ResultsOf 5,058 unique records, 43 were included (37 randomised controlled studies, three non-randomised controlled trials and three before-and-after studies). The proportion of individuals remaining culture-positive on day 1, day 2 and days 3-9 were 6.9% (95% CI: 2.7-16.8%), 5.4% (95% CI: 2.1-13.3%) and 2.6% (95% CI: 1.6-4.2%). For penicillins and cephalosporins, day 1 positivity was 6.5% (95% CI: 2.5-16.1%) and 1.6% (95% CI: 0.04-42.9%), respectively. Overall, for 9.1% (95% CI: 7.3-11.3), throat swabs collected after completion of therapy were GAS culture-positive. Only six studies had low risk of bias.ConclusionsOur review provides evidence that antibiotics for pharyngeal GAS achieve a high rate of culture conversion within 24 h but highlights the need for further research given methodological limitations of published studies and imprecision of pooled estimates. Further evidence is needed for non-beta-lactam antibiotics and asymptomatic individuals.

Throat Swab Culture Positivity and Antibiotic Resistance Profiles in Children 2-5 Years of Age Suspected of Bacterial Tonsillitis at Hargeisa Group of Hospitals, Somaliland: A Cross-Sectional Study.

Tonsillitis is the third most frequently diagnosed infection in the pediatric age and is associated with significant morbidity and loss of school attendance. Throat swab cultures are useful for the confirmation of children with a clinically suspected tonsillitis. However, Somaliland is one of the underdeveloped countries with a low standard of sanitation and poor health seeking culture. Treatment of tonsillitis with antibiotics is irrational and not empirical. This study determined the bacterial throat swab culture positivity and antibiotic resistance profiles of the bacterial isolates among children 2-5 years of age with suspicion of tonsillitis at Hargeisa Group of Hospital, Somaliland. A cross-sectional study was conducted from March to July 2020. A total of 374 children from 2 to 5 years of age suspicion of tonsillitis was included using a convenient sampling method. Throat swabs were collected, and bacterial isolation and identification were done using standard bacteriological procedures. Antimicrobial susceptibility testing was done using the disk diffusion method. Data on demographic variables and clinical profiles were collected using structured questionnaires. Logistic regression analysis was computed to identify factors associated with bacterial tonsillitis. Overall, 120 (32.1%) (95% CI 27.4-36.8%) of children were positive for bacterial throat cultures. Of these, 23 (19.2%) were mixed bacterial isolates. The most frequent bacterial isolates were beta-hemolytic streptococci 78 (55%), Staphylococcus aureus 42 (29%), and Streptococcus pneumoniae 10 (7%). Isolates revealed 83.3-100% rate of resistance to ampicillin. Beta-hemolytic streptococci isolates were 94.9% resistant to ampicillin. S. aureus was resistant to clarithromycin (38%) while S. pneumoniae isolates were 100% resistant to ampicillin. History of tonsillitis (AOR = 0.12; 95% CI = 0.06-0.21), difficulty in swallowing (AOR = 6.99; 95% CI = 3.56-13.73), and attending schools (AOR = 2.98; 95% CI = 1.64-5.42) were found to be associated with positive throat culture. Resistance to ampicillin and MDR among beta-hemolytic streptococci and other isolates of throat colonizers in children with clinically suspected of bacterial tonsillitis are major concerns in Hargeisa, Somaliland. Therefore, treatments of cases are recommended to be guided by regular culture and antimicrobial susceptibility testing to prevent complications of tonsillitis and associated antibiotic resistance.

Challenges in Antibiotics Prescriptions in Paediatrics: A National Survey Among Lebanese Paediatricians

Objectives: The aim of this study, the first of its kind in Lebanon, was to evaluate attitudes and practices of Lebanese paediatricians towards antibiotics prescriptions with a special focus on upper respiratory tract infections to identify challenges facing physicians. Materials and Methods: This was a cross-sectional study conducted among paediatricians registered in the Orders of Physicians. A 63-item questionnaire in English was sent by e-mail or by message to mobile phones of all paediatricians with subsequent reminders. Results: One hundred seventeen physicians agreed to participate in the study. A high proportion of Lebanese paediatricians replied correctly on avoiding antibiotics in cases of cough (86.3%), upper respiratory tract infections (74.4%), tympanic membrane dysfunction (64.1%) and prevention of secondary infection (63%). Eighty percent of physicians prescribed antibiotics for pharyngitis without requesting a throat culture. Most physicians admitted that antibiotic use is considerable in their community and that antibiotic resistance is a threat on the national and international level. Forty percent of paediatricians agreed and strongly agreed that giving advice to parents reduces their antibiotic demand. The same percentage disagreed that they might prescribe antibiotics to gain parents’ trust. Conclusion: National campaigns are required to increase parents’ educations and promote judicious antimicrobial use. Implementing national guidelines, ensuring continuing medical education for doctors and regulating over the counter sale of antibiotics are highly recommended

Changes in external respiration in patients with cystic fibrosis with various infectious pathogens and structural damage to the lungs

The progression of lung failure in children with cystic fibrosis (CF) is associated with chronic lung infection (Staphylococcus aureus, Pseudomonas aeruginosa, Achromobacter spp., etc.). Functional pulmonary tests (PFTs), spirometry and body plethysmography, computed tomography (CT) of the lungs and analysis of the lung microbiota are used for monitoring of lung condition of CF patients. Several studies have been devoted to assessing the correlation of structural changes in CT and pulmonary function tests (PFT), but at the moment there is not enough data on the relationship of these indicators and their differences depending on the respiratory microbiota in CF children in the Russian population. &#x0D; Materials and methods. Data was collected for CF 8–17.9 years children patients. We retrospectively analyzed genotype, body mass index, results of PFTs and CT scan of the chest (score by the Brody scale), deep throat cultures in all patients, and the capillary blood gas — in 56 children. &#x0D; Results. Significant correlations between functional tests and structural changes in the lungs were found. A trend towards impairment of PFTs and CT scores with age due to infectious pathogens was shown, and the most significant negative impact was exerted by the mucoid species Pseudomonas aeruginosa and, especially, Achromobacter spp. The last one was associated with the worst lung parameters in CF children. &#x0D; Conclusion. Pirometry, body plethysmography, and CT of the lungs are necessary for a comprehensive assessment of the lung condition, and a study of the lung microbiome due to its influence on structural and function changes in patients with CF.

Consecutive Seven Serious Cases with Invasive Group A Streptococcal Infections at December 2022-January 2023.

To the Editors: During the second and third year of the COVID pandemic, an increased number of serious cases due to different microorganisms have been reported. In the second half of 2022, it has been reported that there has been an increase in invasive group A streptococcal (iGAS) infections in many countries including England, the Netherlands and others.1–3 iGAS is defined as a life-threatening invasive infection characterized by the isolation of Streptococcus pyogenes from normally sterile body fluids with culture or by pathogen-specific polymerase chain reaction (PCR). If GAS has grown from a probable carrier location, such as the throat, and the clinical course is compatible with GAS disease and no other causing organism has been found, these patients need to be handled as iGAS.4 Before the pandemic, GAS was the most common pathogen among children in Europe who had to be hospitalized for a community-acquired bacterial infection. Patients with GAS infection had a 12% impairment at discharge and a 2% fatality rate. Increases in toxic shock syndrome, necrotizing fasciitis and pleural empyema have all been linked to increased mortality.4 In UK, during the last couple of months, the rate per 100,000 population of iGAS is higher among children.1 Between December 2022 and January 2023, in our tertiary care facility, we followed up 7 consecutive cases of iGAS infection—3 boys and 4 girls, ages 37–96 months—without any relation to one another (Table 1). All children were previously healthy. Five children were admitted to the pediatric intensive care unit, including 1 with toxic shock syndrome and 4 with pleural effusion/empyema. In 6 out of 7 children, the diagnosis of iGAS infection was made based on a positive culture and/or PCR from a typically sterile place, with the pleural fluid being the most frequent site. iGAS infection was defined in a child with toxic shock syndrome based on positive throat culture. In Table 1, antibiotic therapy is displayed. Each patient received clindamycin and 1 patient received intravenous immunoglobulin (IVIG). Due to empyema, thoracic tubes had to be inserted in 5 patients. In 2 of the pleural empyema cases, tube thoracostomy was carried out; in the third video assisted thoracostomy and in the fourth, thoracotomy and decortication were carried out. One child with GAS bacteremia required surgery for mastoiditis, and throughout the course of the investigation, sinus venous thrombosis was detected. Five children required pediatric intensive care unit stay. The length of hospital stay ranged from 7 to 21 days. TABLE 1. - Clinical Characteristics of 7 Children with Invasive Group A Streptococcal Infection Patient Age (month) Gender Diagnosis Culture Multiplex PCR Treatment PICU Stay Length of hospital stay (day) 1 37 Girl Pleural Empyema - Pleural fluid Streptococcus pyogenes Meropenem + vancomycin + clindamycin IVIG Thoracotomy and decortication + 14 2 40 Girl Pleural Empyema Throat Streptococcus pyogenes Pleural fluid Streptococcus pyogenes Tube thoracostomy Ceftriaxone + clindamycin + 9 3 96 Girl Pleural Empyema - Pleural fluid Streptococcus pyogenes Meropenem + vancomycin + clindamycin Tube thoracostomy Video assisted thoracostomy + 15 4 62 Boy Bacteremia, Mastoiditis, Sinus vein thrombosis Blood Streptococcus pyogenes - Meropenem + vancomycin + clindamycin Mastoidectomy - 21 5 48 Boy Pleural Empyema - Pleural fluid Streptococcus pyogenes Ceftriaxone + vancomycin + clindamycin Tube thoracostomy + 10 6 59 Boy Toxic Shock Syndrome Throat Streptococcus pyogenes - Ceftriaxone + vancomycin + clindamycin + 7 7 42 Girl Bacteremia, Pleural Empyema Blood Streptococcus pyogenes - Ceftriaxone + clindamycin - 10 IVIG, intravenous immune globulin; PICU, pediatric intensive care unit. Both the frequency and morbidity of iGAS infections increased after the COVID-19 pandemic as before. While there was only one iGAS case during the previous 3 years, 7 patients in a row were hospitalized during a 2-month period in our setting. Clindamycin would be efficient to deactivate M-protein and these exotoxins because S. pyogenes has the cell wall M-protein that prevents complement activation and reduces phagocytosis. This would produce a positive outcome similar to our case series.4,5 Although culture is the gold standard method for diagnosis, molecular methods such as multiplex PCR are important in identifying the causative agent. Despite treatment, we have seen serious complications in our case series, such as pleural decortication, mastoiditis, sinus venous thrombosis and toxic shock syndrome. Early diagnosis of patients (using molecular techniques included) and the initiation of appropriate treatment including clindamycin, are crucial. To comprehend the postpandemic condition, it is essential to monitor the clinical findings and prognosis of iGAS cases from various countries.

A Surveillance Study of the Serotypes of Streptococci in the Throat and Skin Lesions in Acute Rheumatic Fever and Rheumatic Heart Disease Patients and their Families

Abstract Objectives: The objectives of this study were to determine the colonization of the throat and skin among patients of rheumatic heart disease (RHD) or acute rheumatic fever (ARF) and to elucidate the different Lancefield serotypes of streptococci (Group A, Group C, and Group G) among them. Methods: The prospective observational surveillance study was conducted from November 2016 to March 2018 among 161 enrolled family members belonging to 30 families with one of their patients being diagnosed with RHD/ARF. The outcome measures were period prevalence of serotypes of streptococci, streptococcal colonization of throat and skin lesions, and association of age and antibody titers with RHD/ARF. Results: Out of 30 families enrolled in our study, positive throat (n = 18)/skin (n = 1) cultures were found in 7 families (n = 19). The cultures were positive only for Group A streptococci (GAS), while none of the samples showed positivity for Group C or G serotypes. Overall period prevalence for our study period was 3.2%. Among the 18 members positive for GAS throat culture, 13 (72.2%) belonged to the age group &lt;15 years (P &lt; 0.025). The positive cultures in the throat sample were more in the ARF families than RHD families (P &lt; 0.001). There was no association of culture positivity with antibody titer (P &gt; 0.05). Conclusion: In conclusion, we found only GAS colonization in significantly higher proportion among the family members of cases of ARF in comparison to RHD. Rather there was no case of Group C and G streptococci colonization in cases or family members of RHD/ARF.

Nowadays a New MIS-C Mimicker: Group A Streptococcal Infections.

To the Editors: We show severe streptococcal infections in this report that mimicked the multisystem inflammatory syndrome in children (MIS-C) clinical presentation. At the start of December 2022, the cases were concurrently admitted to our hospital. We would want to share our study considering the Streptococcus pyogenes-related death cases that have recently been reported in many parts of Europe. An 8-year-old female patient complained of chest pain, headaches and fever for 3 days. The patient exhibited a maculopapular rash on the trunk, strawberry tongue, bilateral conjunctivitis, tonsillar hyperemia and cervical lymphadenopathy. Acute phase reactants were noticeably greater and acute renal failure was found in addition to the patient’s lymphopenia (C-reactive protein: 503 mg/L, procalcitonin: 49 μg/L, leucocyte count: 14.700 × 103/μL, lymphocyte count: 100 × 103/μL). The patient was receiving inotropic treatment because of hypotension. A prediagnosis of septic shock and MIS-C was made, and she was monitored in the critical care unit. Treatments with cefotaxime and clindamycin began. Intravenous immunoglobulin (IVIG) (1 g/kg/d for 2 days) and steroid (2 mg/kg/d) treatments were used when the SARS-CoV-2 antibodies were positive. The echocardiogram was normal. Streptococcus pyogenes was produced in the case’s blood culture during the follow-up, confirming the diagnosis of toxic shock syndrome. A 10-year-old female patient presented with complaints of fever, headache, vomiting and weakness for 2 days. The patient with weakness appearance had hyperemic tonsils and bilateral conjunctivitis. In the laboratory results at admission, lymphopenia and increased B-type natriuretic peptide were evident. In the acute phase reactants, the procalcitonin level was 3.7 μg/L and the CRP level was 41 mg/L. The patient had multiorgan involvement, which included the Centers for Disease Control and Prevention case description, thus treatment for MIS-C was initiated in addition to antibiotherapy even though there had been no appreciable increase in inflammatory markers. The patient showed clinical improvement within hours after fluid resuscitation and antibiotic therapy. Influenza was detected in the respiratory viral panel. Upon isolation of Streptococcus pyogenes in the throat culture during the follow-up, the diagnosis was finalized and MIS-C treatment was discontinued and targeted antibiotherapy was continued. This report was presented to highlight severe streptococcal infections mimicking MIS-C. Today, MIS-C, which is characterized by fever, elevated inflammatory markers and multisystem organ involvement, is seen in children following SARS-CoV-2 infection.1 MIS-C is an excluding diagnosis, careful consideration should go into the differential diagnosis. Given that it is overlapped with other prevalent diseases, it is a challenging process for the doctor to treat. In instances with fever, organ involvement and elevated inflammatory markers, empirical antibiotic therapy for potential bacterial agents should be started. In fact, if clinical suspicion is high, antibiotic therapy may be extended. By carefully observing the outcomes of the culture, antibiotherapy can be terminated early in instances where it is not necessary. Viral infections, such as influenza, facilitate the development of group a streptococcal infection, and this increase may have occurred due to the influenza epidemic in the northern hemisphere. The presence of SARS-CoV-2 antibodies in our case with streptococcal toxic shock syndrome increased the suspicion of MIS-C. However, it remains unclear how the antibody test should be interpreted. Because of the increasing prevalence of infection in the community, the usefulness of SARS-CoV-2 antibody testing seems to be limited.2 Therefore, cases with suspected MIS-C should be evaluated from a broad perspective in terms of bacterial infections. Delayed administration of antibiotics may result in mortality.