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Scholars Journal of Applied Medical Sciences (SJAMS) ISSN 2320-6691 (Online)

Abbreviated Key Title: Sch. J. App. Med. Sci. ISSN 2347-954X (Print)
©Scholars Academic and Scientific Publisher
A Unit of Scholars Academic and Scientific Society, India Microbiology
www.saspublisher.com

A Study of Group A Streptococcal Pharyngitis among School Children (3–15‑


Year) of Urban Community
Rao Sadanand LN1, Shanker Venkatesh BM 2*
1
Department of Microbiology, Dr V. R.K Women’s Medical College & Research Centre, Aziznagar, R.R Dist.
Telangana, India
2
Department of Microbiology, Osmania Medical College, Hyderabad, Telangana, India

Abstract: Group A Beta Haemolytic Streptococcal (GABHS) is the most important


Original Research Article gram positive cocci that is very frequently isolated pathogen in pharyngitis and
causing pyogenic infections among school going children and which is linked to the
*Corresponding author etiopathogenesis of its sequel acute rheumatic fever and rheumatic heart disease that
Shanker Venkatesh BM have a worldwide distribution and pose an important health problem. The Present
study is intended to find out the prevalence of Group A beta haemolytic streptococci
Article History (GABHS) related pharyngitis among children of an urban community, and in case of
Received: 27.10.2018 culture being positive its clinical outcome and its relationship to the clinical
Accepted: 05.11.2018 symptoms, and the antibiotic sensitivity pattern of GABHS among children aged 3–15
Published: 30.11.2018 years, presenting with symptoms of sore throat at Dr VRK Teaching HOSPITAL &
Research Centre, a teaching tertiary care hospital, at Aziznagar, Telangana. It was a
DOI: cross sectional, retrospective hospital based study conducted from April 2016 to
10.21276/sjams.2018.6.11.21 March 2017, during this one year period a total of 225 children were examined. Throat
swabs were collected from children with acute pharyngitis (sore throat and fever) and
acute respiratory infection from the paediatric outpatient clinic of the hospital.
Demographic and clinical data were recorded. The collected throat swabs were
processed as per the standard microbiological techniques to isolate GABHS. The disc
diffusion method was used for antimicrobial susceptibility testing. Females were
52.88% and males accounted for 47.12% of 225 children with pharyngitis. The
majority of children belonged to 6-10 years age group (54.22 %) GABHS pharyngitis
was found more among females and in the age group of 6-10 years. The presenting
symptom in most of the cases was pain in the throat with Cough and with the presence
of exudates as specific sign in most of the cases of GABHS. The findings showed the
prevalence of (26%) of GABHS isolation among the children. All isolates of GABHS
were(100%) susceptible to penicillin and Vancomycin and (76.27%) sensitive to
Clindamycin and tetracycline, the highest resistance was shown to Amoxicillin. As
there is a direct correlation between the incidence of Group A beta-haemolytic
streptococci and the symptomatic paediatric patients presenting with sore throat and
fever, the current findings underscore the need to increase awareness about appropriate
throat examination and treatment of sore throat among primary care physicians and
also this study highlights the importance of regular screening and regular surveillance
to keep the GABHS in check and to control the development of non-supportive sequel,
by treating children judiciously with appropriate antibiotics.
Keywords: Sore Throat, Gabhs, Penicillin.

INTRODUCTION Group A beta haemolytic streptococcus


Streptococci are gram positive cocci arranged (GABHS) a Gram positive spherical bacterium is the
in chains or pairs and are part of normal flora of essential and frequently encountered human pathogen
humans and animals. The most important of them is all over the world especially among children between
Streptococcus pyogenes a human pathogen causing 3-15 years which is a great burden on school-aged
pyogenic infections, with a characteristic tendency to children[1] causing a broad spectrum of diseases
spread, as opposed to staphylococcal lesions which are ranging from uncomplicated pharyngitis and pyoderma
typically localized. to invasive, life-threatening immunological
complications such as acute rheumatic

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Rao Sadanand LN & Shanker Venkatesh BM., Sch. J. App. Med. Sci., Nov, 2018; 6(11): 4269-4274
fever (ARF), rheumatic heart disease (RHD), post Exclusion criteria
streptococcal glomerulonephritis (PSGN), toxic shock  Documented antibiotic use during last three days
syndrome (TSS) and necrotizing fasciitis[2,3].  Documented use of intramuscular benzathine
penicillin G during last 28 days
GABHS are normal inhabitants of the  Presence of ear discharge or impetigo at the time of
oropharynx and skin. Colonization of the throat with examination
GABHS may occur in 10-20% of normal school aged  History of previous rheumatic fever or rheumatic
children. These children are carriers and do not get heart disease
infected nor are at risk of developing RF [4] but serve  Presence of any other infection requiring
as a reservoir for pathogen. antibiotics
 Presence of any other known severe illness
Group a beta‐haemolytic streptococcus is a requiring hospitalization; EXCEPT: malnutrition or
common cause of acute pharyngotonsillitis accounting tuberculosis;
for 10–30% of episodes in children and 5–10% in adults  Physician’s diagnosis of wheezing, bronchitis, or
[5]. pneumonia
 Parent’s or guardian’s consent not available
Globally, it is estimated that about 600 million
cases of symptomatic GABHS pharyngitis occur
The identification of each child and other
annually among people aged over 5 years and over 550
information like demographic variables , medical
million of these occur in less developed countries. The
history like - the duration of illness before their visit,
greatest global burden of GABHS disease is due to
related symptoms like sore throat, running nose, cough,
RHD which follows GABHS pharyngitis, where 15
swollen neck glands, general aches, rash,
million cases and 349,000 deaths occur worldwide
gastrointestinal discomfort, history of a temperature,
annually. Ninety-five percent of the disease burden
history of recurrent attacks of tonsillitis, episodes per
from RHD is in low and middle income countries where
year and multiple treatment courses and signs like
it continues to have a significant impact on the health of
tonsillar swelling, tonsillar exudates, tender anterior
children and young adults. There are 2.4 million
cervical lymph node, a rash typical of scarlet fever,
affected children between 5 and 14 years of age in
abnormal tympanic membrane, and lung findings,
developing countries [6-8]. RF and Acute Glomerular
laboratory investigations were all recorded.
Nephritis are major health problems in the developing
world. The incidence of RF declined in industrialized
SAMPLE COLLECTION & PROCESSING
countries, since the 1950's and now has an annual
With the sterile cotton swab applicator, two
prevalence of 0.5 cases per 1,00,000 children. In
samples were collected from the patient’s posterior
developing countries it remains an endemic disease
pharynx and tonsillar surfaces by rubbing vigorously
with annual incidence ranging from 100 to 200 per 1,
avoiding the surrounding tissues. One of the swab is
00,000 school children and is a major cause of cardio-
used for direct smear preparation by Gram staining and
vascular mortality. RF is reported to occur in 1-3
the other swab was put into Amies transport medium
percent of streptococcal throat infections of children
and transported to the Clinical Microbiology
living in underprivileged conditions [9].
Laboratory within 2 hours and were inoculated onto 5%
sheep’s blood agar plates and incubated for 24 h at
OBJECTIVES
37 °C in a candle jar, which can provide an atmosphere
The main aim was to determine the
of 5% CO2. Culture plates negative for β-haemolytic
prevalence, antimicrobial susceptibility pattern and
colonies were incubated for additional 24 hours to
clinical predictors of GABHS among children with
allow the growth of slow growers. Beta-haemolytic
pharyngitis.
streptococci isolates were phenotypically identified by
standard microbiological techniques : which include β-
MATERIALS & METHODS
haemolytic activity on sheep’s blood agar, small colony
Two hundred twenty five children seeking care
morphology, Gram stain revealing Gram
at the paediatric outpatient clinic of the Dr VRK
positive cocci,negative catalase test, susceptibility to
Teaching HOSPITAL & Research Centre, a teaching
0.04-U Bacitracin disc( Isolates with a zone of inhibited
tertiary care hospital, at Aziznagar, for pharyngitis (sore
growth around the Bacitracin disc of >15 mm diameter
throat and fever)& acute respiratory infection, were
were considered potential GAS).
included in this cross sectional, retrospective study
conducted from April 2016 to March 2017 ( one year)
Presumptive identification of a strain as a
Group a Streptococcus was also made on the basis of
Inclusion criteria
production of the enzyme L-pyrrolidonyl-beta-
 Male and female children aged 3–15 years naphthylamide (PYRase test). Among the beta-
 Child with at least one of the following symptoms haemolytic Streptococci isolated from the throat
were only included:

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Rao Sadanand LN & Shanker Venkatesh BM., Sch. J. App. Med. Sci., Nov, 2018; 6(11): 4269-4274
culture, only Group An isolates produce PYRase and In this study, the subjects were divided into
hence PY Rase test was also conducted in the samples three groups based on their age into : 3 to 5 years- in
which there were 48 children and the majority were in
GAS identification by Latex agglutination test the 6-10 age group -122 and the rest 11 to15 age group
The presumptive identification was further in which there were 55 (Table 2)
confirmed by latex agglutination tests containing group
a specific antisera (Commercially available) Among the 3 to 5 years age group in which
there were 48 children ,males were 11 and females were
Antibiotic susceptibility testing 37; in the 6-10 age group out of total 122, males were
Antimicrobial susceptibility testing was done 55 and females were 67; and in 11 to15 age group in
by using the disc diffusion method according to criteria which there were total 55, males were 40 and females
set by Clinical Laboratory and Standard Institute were 15; (Table 3)
(CLSI).
In the present study, out of the 225 samples
The antibiotic discs were selected based on collected and processed, Group A β-haemolytic
prescription pattern and recommendations from CLSI. streptococci was isolated in 59 samples, as identified by
The following antimicrobial discs with respective standard microbiological techniques and the specific
concentration were tested for Susceptibility. identification tests such as Bacitracin sensitivity test,
PYRase test and latex agglutination test (Table 4).
Penicillin (10 unit), Ceftriaxone (30 μg),Chlor
amphenicol (30 μg), Amoxicillin (25 μg), Erythromycin Streptococcus pyogenes was isolated in 59/225
(15 μg), Clindamycin (2 μg), Tetracycline (30 μg) (26.21%)patients, out of which 30 (50.85%)were from
Clarithromycin (15 µg), Azithromycin (15 µg) and the age group 6-10 years; between 11-15 years age 17
Vancomycin (30 µg). Zone of inhibition diameters were (28.81%) and from the age group 3-5 years 12
interpreted as per CLSI guidelines (20.34%)(Table 5).

RESULTS The antimicrobial drug susceptibility profile


A total of, 225 children between ages of 3 to15 which was done by the modified Kirby – Bauer disc
years with pharyngitis & acute respiratory infection, diffusion method on Mueller Hinton agar (MHA) under
seeking care at the paediatric outpatient clinic of the standard conditions in accordance to latest CLSI
Dr VRK HOSPITAL, a teaching tertiary care hospital, guidelines revealed that all GABHS isolates (59) were
at Aziznagar, were enrolled from from April 2016 to not only 100% sensitive to Penicillin G and
March 2017 (one year). Among them, 106 (47.7%) Vancomycin but also showed variable resistance to
were males and 119 (52.3%) were female children. The certain other antibiotics that were tested (Table 6)
prevalence was higher in girls as compared to boys
(Table 1).

Table-1: Showing Sex distribution


Sl.no SEX No.of cases Percent
1 Males 106 47.12%
2 Females 119 52.88%

Table-2: Showing Age distribution


Sl.no AGE No.of cases Percent
1 3 – 05 yrs 48 21.33%
2 06 - 10 yrs 122 54.22%
3 11 -15 yrs 55 24.45%

Table-3: Distribution of Males & Females


Sl.no Age Total No. of Male Female
cases (225)
1 03 – 05 yrs 48(21.33%) 11 (4.89%) 37 (16.44%)
2 06 - 10 yrs 122(54.22%) 55 (24.45%) 67 (29.77%)
3 11 -15 yrs 55(24.45%) 40 (17.78%) 15 ( 06.67%)

Table-4: Showing GABHS ISOLATION


Sl.no Total No. of cases Gabhs Isolated Sterile
1 225 59(26%) 166(74%)

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Rao Sadanand LN & Shanker Venkatesh BM., Sch. J. App. Med. Sci., Nov, 2018; 6(11): 4269-4274
Table-5: Showing distribution of GABHS among male and females
Sl. Age Total no.of Gabhs isolated (59) Total
no cases(225) Male Female
1 03– 05 yrs 48 04 08 12
2 06 - 10 yrs 122 10 20 30
3 11 -15 yrs 55 07 10 17
TOTAL 21(9.33%) 38(16.88%) 59(26.21%)

DISCUSSION The difference prevalence rates could be due


In our study Prevalence of group A to difference in climatic condition, socio-economic
streptococcal infection were more in females (16.88%) conditions and geographical regions.
in comparison to males ((9.33%), which has similar
findings with the study conducted by Gupta R et al. In this study it was found that all the isolates
[14]. of Streptococcus pyogenes were 100% susceptible to
penicillin & Vancomycin followed by clindamycin,
In studies conducted by Moses et al. [19] and tetracycline (76.27%), ceftriaxone (59.3%),
Giir E et al.[17] males outnumbered females. No male- Chloramphenicol (42.37%), Erythromycin,
female disparity in the prevalence rate of group a Azithromycin and Clarithromycin (32.2%) least
streptococcal infection was shown in other studies sensitivity to Amoxicillin (13.56%) This result is in
conducted by Madha S et al. [20] and Rijal K R et al. accordance with study conducted by Rijal KR et al.
[21]. [21], Metin Dogan et al. [31], Shet et al. [32],
Haczynski J et al. [33] and Capoor MR et al. [34]
As per our study there was a higher prevalence respectively. However, it is important to know that
of Streptococcus pyogenes in the age group between 6- sometimes antibiotic susceptibility pattern may vary
10 years. This has Similarity to other studies conducted with different GABHS strains, geographic area and
by Lin MH et al. [27] and Gupta R et al. [14]. Davies immunity profile of the study population [35].
HD et al. [28] and Gunnarssu RK et al. [29]. Farheen
Fatima et al. [30] and KR Rijal et al. [21] also reported CONCLUSION
maximum number of BHS in age group 6-10 years As there is a direct correlation between
(33.5%). prevalence of Group A beta haemolytic streptococcal
and symptomatic paediatric patients presenting with
As per our study isolation of GABHS from sore throat and fever, this study highlights the
among the studied subjects was 59(26%).This is similar importance of regular screening and the regular
to with the previous studies conducted by Sanjeeb surveillance to keep GABHS in check and to control the
Sharma et al. [15], Basili A et al.[16], Giir E et al. [17], development of non-supportive sequel, by treating
Gupta R et al. [14] Nirmal Kushwaha et al.[18] which children early with appropriate antibiotics by routine
showed overall prevalence of GABHS ranging from 17 culture and sensitivity and also highlights upcoming
to 25%. drug resistance to the commonly used antibiotics which
may be due to injudicious and excessive use of
But other studies conducted in the various antibiotic therapy without following proper antibiotic
parts of our country by Gupta R et al. [14], Muthusamy policy.
D et al. 22, Lloyd C.A et al. [23], the overall prevalence
of beta-haemolytic Streptococci among the throat swabs The prevalence of rheumatic heart disease
of the children was less than those which were isolated (RHD) has declined in the western hemisphere but
in our study. continues to be an important cause of cardiovascular
morbidity in India According to a survey by the Indian
In some other studies from Chennai by Council of Medical Research the prevalence rate in
Kalpana S et al. [24] (53.5%), by Sugumari school age children is 5.3 per 1000. The pattern of
Chandrasegaran et al. [25] at Madurai (78%), severe juvenile RHD characteristically noted in India,
Lakshmana Gowda Krishnappa et al. [26] (83.6%), the expense of chronic drug therapy, repeated
reported a high isolation of β-haemolytic streptococcus hospitalization and high surgical costs make its
in the symptomatic school children. prevention and control a major public health priority.
Control of RHD entails the prevention of rheumatic
The prevalence rate of BHS in developing fever (RF) and its antecedent streptococcal pharyngitis.
countries varies widely from 9.2% to as high as 28.9%. While an improved socio-economic situation, with
Prevalence of GABHS pharyngitis in India ranges from alleviation of overcrowding and improvement of
4.2% to 23.7%, which are comparable to the rates nutrition being the major factors contributing to the
reported from the developed countries. decline of streptococcal pharyngitis and its sequelae
(RF and RHD), developing countries need to depend on

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Rao Sadanand LN & Shanker Venkatesh BM., Sch. J. App. Med. Sci., Nov, 2018; 6(11): 4269-4274
anti-streptococcal drugs such as penicillin for interim for vaccine development. Lancet Infect Dis.
programmes of prevention. 2009;9(10): 611–616.
9. Park K. Rheumatic Heart disease. In: Textbook of
Prophylaxis may be primary (prevention of the preventive and Social Medicine.Sixteen edition. M/
first attack of RF) or secondary (prevention of the s Banarsidas Bhanot, 1167, premnagar, Jabalpur
recrudescence of RF). Primary prophylaxis aims at the (India). 1997: 279
prompt treatment of streptococcal pharyngitis with 10. Shah B, Ganguly NK. Epidemiology of group A
penicillin so that RF does not occur. Secondary streptococcal pharyngitis & impetigo: a cross-
prophylaxis consists of regular long term (preferably sectional & follow up study in a rural community
lifelong) periodic administration of benzathine of northern India. Indian J Med Res. 2009
penicillin to persons who have RHD or have had an Dec;130:765-71.
attack of RF. 11. Kalpana S, Sundar JS, Parameshwari S,
Kuganantham P, Selvam JM, Valarmathi S, Datta
As methods for streptococcal control M. Isolation and Identification of Group A
programme have now become cost effective, such Streptococcal Infection Among Slum Children in
programmes should be incorporated into any prevention the Age Group of 5-15
methods for control of RF and RHD, and children 12. Years in Chennai - One Year Prospective Study.
below 11 years may require a special attention Journal of Pharmacy and Biological Sciences July-
regarding prevention of streptococcal infection. August. 2012; 2(1): 27-30
13. Bisno AL, Gerber MA, Gwaltney Jr JM, Kaplan
EL, Schwartz RH. Practice guidelines for the
REFERENCES diagnosis and management of group A
1. Dunne EM, Marshall JL, Baker CA, Manning J, streptococcal pharyngitis. Clinical infectious
Gonis G, Danchin MH, Smeesters PR, Satzke C, diseases. 2002 Jul 15:113-25.
Steer AC. Detection of group a streptococcal 14. Martin JM & Green M. Group A
pharyngitis by quantitative PCR. BMC infectious streptococcus. Seminars in Pediatric Infectious
diseases. 2013 Dec;13(1):312. Diseases. 2006; 17, 140–148
2. Langlois DM, Andreae M. Group A streptococcal 15. Gupta R, Prakash K, Kapoor AK. Subclinical
infections. Pediatrics in Review-Elk Grove. 2011 group A streptococcal throat infection in school
Oct 1;32(10):423. children. Indian pediatrics. 1992 Dec;29(12):1491-
3. Kovarik P, Castiglia V, Janos M. Type I 4.
Interferons in Immune Defense Against 16. Sharma S, Praveen S, Devi KS, Sahoo B, Singh
Streptococci. InBacterial Activation of Type I WS, Singh TD. Prevalance of Streptococcus
Interferons 2014 (pp. 43-59). Springer, Cham. pyogenes infection in children aged between 5 to
4. James K. Todd. Group A streptococcus. In: 15 years with acute tonsillopharyngitis and its
Behrman RE, kliegman RM, Jenson HB. Nelson antibiogram. IOSR J. Dent. Med. Sci.(IOSR
Text book of Pediatrics, 16th edition W.B. JDMS) 2279-0861. 2014 Nov;13(11):50-5.
Saunders Company. 2000; 802 17. Bassili A, Barakat S, Sawaf GE, Zaher S, Zaki A,
5. Wessels MR. Streptococcal pharyngitis. New Saleha EE. Identification of Clinical Criteria for
England Journal of Medicine. 2011 Feb Group A‐β Hemolytic Streptococcal Pharyngitis in
17;364(7):648-55. Children Living in a Rheumatic Fever Endemic
6. Carapetis JR, Steer AC, Mulholland EK, Weber M. Area. Journal of tropical pediatrics. 2002 Oct
The global burden of group A streptococcal 1;48(5):285-93.
diseases. Lancet Infect Dis. 2005;5 (11):685–694. 18. Giir E, Akkus S, Arvas A, Giizeloz S, Can G,
7. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Diren S, Prevalence of positive throat cultures for
Rowley AH, Shulman ST, Taubert KA. Prevention group A beta-hemolytic streptococci among school
of rheumatic fever and diagnosis and treatment of children in Istanbul, Indian Pediatr. 39, 2002, 569-
acute Streptococcal pharyngitis: a scientific 73.
statement from the American Heart Association 19. Kushwaha N, Kamat M, Banjade B, Sah J.
Rheumatic Fever, Endocarditis, and Kawasaki Prevalence of Group-A Streptococcal Infection
Disease Committee of the Council on Among School Children of Urban Community–A
Cardiovascular Disease in the Young, the Cross Sectional Study. Int J interdiscip Multidiscip
Interdisciplinary Council on Functional Genomics Stud. 2014;1:249-56.
and Translational Biology, and the Interdisciplinary 20. Moses AE, Goldberg S, Korenman Z, Ravins M,
Council on Quality of Care and Outcomes Hanski E, Shapiro M. Invasive group A
Research: endorsed by the American Academy of streptococcal infections, Israel. Emerging
Pediatrics. Circulation. 2009; 119(11):1541-51. infectious diseases. 2002 Apr;8(4):421.
8. Steer AC, Law I, Matatolu L, Beall BW, Carapetis 21. Saleh MM. Streptococcal throat infection among
JR. Global emm type distribution of group A Yemeni children. Iraqi Journal of Science.
Streptococci: systematic review and implications 2009;50(1):126-35.
Available online: http://saspublisher.com/sjams/ 4273
Rao Sadanand LN & Shanker Venkatesh BM., Sch. J. App. Med. Sci., Nov, 2018; 6(11): 4269-4274
22. Rijal KR, Dhakal N, Shah RC, Timilsina S, Mahato 30. Davies HD, Mc Geev Allison, Schwartz Benjamin,
P, Thapa S, Antibiotic susceptibility of group A Green Karen, Cann Darlene, Simmon Andrew,
Streptococcus isolated from throat swab culture of Invasive group A streptococcal infection in Ontario
school children in Pokhara, Nepal. 11(4), 2009, Canada, N Engl J Med. 1996, 547-54
238-40 31. Gunnarsson RK, Holm SE, Söderström M. The
23. MUTHUSAMY D, BOPPE A, SURESH SP. The prevalence of beta-haemolytic streptococci in
Prevalence of Group A Beta Haemolytic throat specimens from healthy children and adults:
Streptococcal Carriers Among School Children in implications for the clinical value of throat
Coimbatore, South India. Journal of Clinical & cultures. Scandinavian journal of primary health
Diagnostic Research. 2012 Sep 1;6(7). care. 1997 Jan 1;15(3):149-55.
24. Lloyd CA, Jacob SE, Menon T. Pharyngeal 32. Fatima F, Shubha DS. Prevelance Survey for
carriage of group A streptococci in school children Assessing Intensity of Group A Beta Hemolytic
in Chennai. Indian Journal of Medical Research. Streptococci (GABHS) Subclinical Infection Rate
2006 Aug 1;124(2):195. in School Children: A Cross Sectional Study.
25. Kalpana S, Sundar JS, Parameshwari S, Global Journal of Medical Research. 2013 May 17.
Kuganantham P, Selvam JM, Valarmathi MS, 33. Dogan M, Aydemir O, Guner SN, Feyzioglu B,
Datta M. Isolation and identification of group A Baykan M. Antibiotic Susceptibility of Group A B-
streptococcal infection among slum children in the Hemolytic Streptococci Isolated From Tonsillar
age group of 5-15 years in Chennai-one year Swab Samples in 5-15 Years Old Children.
prospective study. Age. 2012;5(10yrs):313. ELECTRONIC JOURNAL OF GENERAL
26. Years in Chennai. One Year Prospective Study. MEDICINE. 2014 Jan 1;11(1):29-32.
Journal of Pharmacy and Biological Sciences July- 34. Shet A, Kaplan E. Addressing the burden of group
August. 2012; 2(1): 27-30 A streptococcal disease in India. The Indian
27. Chandrasegaran S, Subramaniyan MP. Prevalence Journal of Pediatrics. 2004 Jan 1;71(1):41-8.
of beta-haemolytic streptococcal throat infections 35. Haczyński J, Bardadin J, Gryczyńska D,
in paediatric age group in Madurai. Journal of Gryczyński M, Gołabek W, Kawalski H, A
Evolution of Medical and Dental Sciences. 2016 comparative study of cefaclor versus
Jul 21;5(58):3980-5. amoxicillin/clavulanate in tonsillopharyngitis, Med
28. Krishnappa LG, Marie MA, John J, Thippana SC, Sci Monit. 7(5), 2001, 1016-22.
Gopalkrishnan S, Narayan BK. A community- 36. Capoor MR, Nair D, Deb M, Batra K, Aggarwal P.
based study of the rate of beta-hemolytic groups Resistance to erythromycin and rising penicillin
streptococcal infections in symptomatic and MIC in Streptococcus pyogenes in India. Japanese
asymptomatic school children. Journal of journal of infectious diseases. 2006 Oct
laboratory physicians. 2014 Jan;6(1):64. 1;59(5):334.
29. Lin MH, Fong WK, Chang PF, Yen CW, Hung 37. Dhanda V, Chaudhary P, Toor D, Kumar R,
KL, Lin SJ. Predictive value of clinical features in Chakraborti A. Antimicrobial susceptibility pattern
differentiating group A beta-hemolytic of beta-haemolytic group A, C and G streptococci
streptococcal pharyngitis in children. Journal of isolated from North India. Journal of medical
microbiology, immunology, and infection= Wei microbiology. 2013 Mar 1;62(3):386-93.
mian yu gan ran za zhi. 2003 Mar;36(1):21-5.

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