Diagnosis and treatment of group A beta hemolytic streptococcal pharyngitis in children in low and middle income countries

Background. Group A Beta Hemolytic Streptococcal (GABHS) pharyngitis is the precipitating cause of rheumatic heart disease (RHD). Primary prevention of RHD is accomplished through identification and antibiotic treatment of GABHS pharyngitis to eradicate the bacteria from the pharynx.; Design and methods. The diagnostic arm of this study was designed as a descriptive study of prospectively enrolled children in Brazil, Croatia, Egypt and India. In Croatia and Egypt, children with a positive rapid antigen test for GABHS participated in the therapeutic arm of the study which was a treatment trial comparing a single dose of intramuscular benzathine penicillin G (600,000–1.2 million IU) with once daily oral amoxicillin (750 mg) for ten days. Overall, 1312 patients were recruited for the diagnostic arm of the study. A total of 248 patients were recruited (122 in Egypt and 126 in Croatia) in the therapeutic arm of the study.; Results. In this dissertation, there are three papers describing the results of the study. In the first paper we found that there were substantial differences in clinical presentation of non-specific pharyngitis syndrome across the four countries. The only sign associated with GABHS pharyngitis across all sites was enlarged cervical lymph nodes. In the second paper our clinical prediction rule for presumptive diagnosis of GABHS pharyngitis of enlarged cervical lymph nodes or tonsillar enlargement had improved sensitivity (84.0–88.3% across populations) over the currently recommended WHO rule and moderate specificity (26.6–37.6%) in the Croatia, Egypt, and combined populations. In the third paper we found that there were not significant differences in microbiologic effectives of intramuscular benzathine penicillin G and oral amoxicillin.; Conclusions. Our results indicate that (1) there appear to be substantial differences in clinical presentation of nonspecific pharyngitis syndrome across the 4 countries, but less variation in signs associated with GABHS. (2) Our clinical prediction rule has superior sensitivity than the currently recommended WHO treatment guideline and performs similarly in two countries with different populations. (3) A single dose of intramuscular benzathine penicillin G and a daily dose of amoxicillin for ten days do not differ significantly in terms of microbiological effectiveness.