The economic effects of the disability and premature death caused by these diseases are felt at both the indi- vidual and national levels through increased direct and indirect health care costs. The most cost effective ap- proach for the control of RHD is secondary prophylaxis with penicillin injection every 3 or 4-weeks . Careful penicillin delivery results in recurrence prevention also in high risk areas . However, in our study setting in Ethiopia, implementation of secondary antibiotic preven- tion is challenged by missed opportunities for treatment, poor access to health care and inadequate treatment of tonsillopharyngitis with failure to eradicate S. pyogenes from the throat [14, 16]. Therefore, we investigated the throat culture positivity rate, BHS strain types and anti- biotic susceptibility patterns and their relations to dose intervals of penicillin in children on secondary prophy- laxis for RHD at TASH.
This large prospective study found that the sensitivity of throat cultures performed in the office was significantly greater than the sensitivity of office RADTs. However, both the office RADT and the office BAP culture dem- onstrated relatively low sensitivity overall. The RADT, office BAP culture, and office BAP culture confirmation of negative RADT results all exhibited spectrum bias, which supports selective testing of patients with phar- yngitis. In areas with low rates of GAS complications, such as North America and Western Europe, the diag- nostic paradigm for pharyngitis should emphasize selec- tive swabbing to avoid testing of patients who are un- likely to have GAS pharyngitis and avoidance of antimicrobial overuse through treatment only of pa- tients with positive test results.
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pharyngitis recommends that patients whose clinical presentation is consistent with GAS pharyngitis be tested with a streptococcal rapid antigen detection test (RADT) or throat culture; treatment is indicated if either is positive. Testing is not recommended for patients whose presentation is most consistent with a viral etiology . The American Academy of Pediatrics (AAP) has made similar recommendations . None- theless, studies evaluating the management of pharyn- gitis among pediatric providers have identified high rates of antibiotic prescribing , even for patients with negative GAS tests . To our knowledge, no study in a pediatric population has yet evaluated adherence to IDSA guidelines using individual patients’ clinical data and test results.
A pproximately 8% percent of office visits in our private group practice are for the pre- senting complaint of sore throat. Group A ␤ -hemolytic streptococcal (GABHS) pharyngitis is diagnosed in 20% to 30% of these visits. The standard method for establishing the etiologic diagnosis of GABHS pharyngitis is culture of a pharyngeal spec- imen obtained with a throat swab and inoculated on sheep blood agar. However, the throat culture re- quires 24 to 48 hours to interpret, thus delaying the diagnosis. Rapid antigen detection (RAD) tests that detect the group A carbohydrate of the bacterial cell wall are used to expedite the diagnosis. In our phy- sician office laboratory, a RAD test is performed on each throat swab. A positive RAD test result is ac- cepted as adequate for the diagnosis of GABHS phar- yngitis because of the high specificity of the test. 1,2
a problem are systematically considered. Medical decision analysis may be used to facilitate making complex treatment choices amid diagnostic uncer- tainty and demonstrate cost-effectiveness. For these reasons, decision analysis is used here. This is not the first decision analysis to be applied to the treatment of streptococcal pharyngitis, but it differs from those previously published in that it includes the option of using a new, rapid diagnostic technique that may have sensitivity superior to that of sheep blood agar throat culture in most settings. It is also the first study to use current probability estimates for acute rheumatic fever, a nonsuppurative complication of GABHS infections that has become rare in the United States. This study is also the first to include the value of patient time spent waiting for a diagnostic result. As a decision analysis relies completely on the accuracy of the data used in its creation, all data must be scrutable. In this analysis, care was taken to use the best cost and probability assumptions available. As this analysis sought to update many of the cost and probability assumptions used in a previously published pediatric decision analysis, the assump- tions of this earlier analysis were used wherever appropriate. Updated cost and microbiology as- sumptions accurately represent those found in our office and its affiliated tertiary care medical center,
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Results: All participants had negative results of throat culture for GAS and had no history of documented streptococcal infection in the past year. Our results indicate that new-onset CD, but not CD in remission or active CD, is associated with signi ﬁ cantly increased positive ASO compared to controls. Half of the patients in the new-onset CD group were ASO positive, which was signi ﬁ cantly higher compared to the control group in a univariant (OR: 4.00; 95% CI 1.27 – 12.58; P=0.02) and multivariant analysis (OR: 4.41; 95% CI 1.35 – 14.37; P=0.014). Conclusion: Our study is the ﬁ rst to focus on ASO levels in patients with CD and to demonstrate a signi ﬁ cant association between ASO and new-onset of CD. Large prospective randomized controlled studies are needed to con ﬁ rm the validity of this data and to further clarify the clinical signi ﬁ cance of our ﬁ ndings.
O ur patient (C.W.) is a 15-year-old girl who was well until 6 days before her admission when she developed cough, congestion, sore throat and mild abdominal pain. She presented to her primary care physician on the second day of her illness when she developed a fever. A throat culture for Strepto- coccus pyogenes was negative, and she was treated with appropri- ate doses of acetominophen and ibuprofen. On the fourth day of her illness, she became acutely worse, with persistent fevers to 104°F, vomiting, diarrhea, decreased oral intake, dizziness, persis- tent severe abdominal pain, headache, “stinging” sensations in her extremities and severe myalgias that made it difficult for her to walk without assistance. On the morning of admission, her urine was brown, and she presented to the emergency department for evaluation. Of note, she had a negative history for rash, sick contacts, recent travel, recent trauma, pet exposures, dysuria, change in mental status, a recent increase in her exercise level, a history of blood transfusions or prior episodes similar to the current one. She presented in early October, before the height of the influenza season. She was sexually active, but had no history of sexually-transmitted diseases and had used condoms with each sexual encounter.
The diagnosis of GABHS pharyngitis can be done by a throat culture or rapid diagnostic test for GABHS (RADT). The culture is the gold standard for diagnosis but requires 18-24 hours of incubation at 37°C, causing a delay in identification of GABHS. This delay in diagnosis often leads physicians to administer therapy without first knowing the etiological agent, causing an overuse of anti- biotics that provokes a rising in the diffusion of drug- resistant bacterial strains. RADTs allow the identification of GABHS on a throat swab in a matter of minutes. This strategy has a significant impact on reducing the antibio- tic prescription . The tests are based on nitrous acid extraction of group A carbohydrate antigen from organ- isms obtained by throat swab. The specificities of RADTs are generally high while sensitivities vary considerably . Rapid tests offer good accuracy for use as diagnostic method, however, in some situations, they have to be complemented with the microbiological culture, because of the possibility of false negative results . Tanz et al in a study including 1848 children from 3 to 18 years evaluated for acute pharyngitis in 6 community pediatric offices demonstrate that Rapid antigen-detection test sensitivity was 70%. Office culture sensitivity was signifi- cantly greater, 81%. Rapid antigen-detection test specifi- city was 98%, and office culture specificity was 97%, a difference that was not statistically significant . Table 1 Clinical signs and symptoms of GABSH
A variety of mouth and throat disorders exist in South Africa and the increasing severity and prevalence thereof are of major concern. Proper oral hygiene plays a vital role in overall health status. Patients have a variety of OTC mouth and throat preparations in a range of dosage forms to choose from based on personal preference. The majority of the preparations provide symptomatic relief of inflamed, painful or irritated mouths and throats. There are also OTC preparations available for the treatment of fungal infections and for use in dental procedures.
Not all sore throats are caused by infection. Post nasal drip can irritate the throat and make it sore. It can be caused by hay fever and other allergies that irritate the sinuses. Environmental and other conditions, such as heavy smoking or breathing second-hand smoke, heavy alcohol consumption, breathing polluted air or chemical fumes, or swallowing substances that burn or scratch the throat can also cause pharyngitis (Sore throat). Dry air, like that in airplanes or from forced hot air furnaces can make the throat sore. People who breathe through their mouths at night because of nasal congestion often get sore throats that improve as the day progresses. Sore throats caused by environmental conditions are not contagious.
Daruharidra  , the main ingredient of Dar- vyadi kwath has Tikta, Kashaya rasa, Katu vipak, Ushna virya, Laghu, ruksha guna. It is useful in alleviating of Pitta and Kapha doshas which are the main culprit behind throat infections. Its bark contains an alkaloid Berberine which possess antibacterial, anti- fungal, antiviral, antioxidant and anti- inflammatory properties. Daruharidra possess shothaghana (Anti-inflammatory), Jwaraghna (Antipyretic) and Kaphaabhishyandahara properties (Drying quality). It is said that Da- ruharidra has properties similar to turmeric but it is mainly useful for Karnanetramukha rogas  (Ear, nose, throat disorders). Rasan- jana, the second most important ingredient, is the crude extract of Daruharidra.
We developed a one-step single-tube accelerated real-time quantitative RT-LAMP assay for the early and rapid diagnosis of SARS-CoV. The assay can detect SARS-CoV at an early stage of infection by using throat washes and combined throat and nasal swab specimens. The evaluation of the RT-LAMP assay for detection of viral RNA in clinical specimens has been validated with 59 samples, including 15 throat washes, 13 throat swabs, 21 combined throat and nasal swabs, and 10 healthy throat wash samples collected from the Hanoi-French and Ninhbinh hospitals during the SARS epidemic in Vietnam, and results were compared with those of conventional RT- PCR. Of 49 samples, 10 samples were confirmed to be SARS- CoV, as reported by the Centers for Disease Control and Prevention, by using virus isolation and/or nested RT-PCR methods, and 35 samples were grouped as probable or sus- pected cases based on the WHO case definition.
Human rhinovirus (HRV) accounts for a significant portion of common-cold illness, with the peak incidence being in the early fall. Three hundred forty-six adults who had self-diagnosed colds of 48 h or less were enrolled in a study during September and October 1994 to determine the frequency and clinical course of HRV infections. Nasal wash specimens for viral culture and reverse transcription-PCR (RT-PCR) for HRV RNA and human coronavirus OC43 and 229E RNA detection were collected on enrollment, and participants recorded their symptoms twice daily for 14 days. Middle ear pressure (MEP) was measured with a digital tympanometer on days 1 and 7. Picornaviruses (224 HRV and 7 enterovirus isolates) were detected by culture in 67% (231 of 346) of the subjects. Among 114 samples negative by culture, HRV was detected by RT-PCR in 52 (46%) for an overall picornavirus infection rate of 82% (283 of 346 subjects). Among the remaining 62 negative samples, human coronavirus RNA was detected by RT-PCR in 5 patients, so that 288 (83%) of patients had documented viral infection. The first symptom noticed most often was sore throat (40%) in HRV culture- or PCR-positive patients and stuffy nose in HRV-negative patients (27%). No differences in symptom scores over time or in the presence of individual symptoms were noted between groups. The median duration of the cold episodes was 11 days in HRV culture-positive patients, 9.5 days in HRV RT-PCR-positive patients, and 11.5 days in HRV- negative patients. On enrollment, abnormal MEPs ( < 2 100 or > 1 100 mm of H
Consequences of a failure to make an etiologic diagnosis. The consequences of a failure to identify and treat GAS pharyngitis with antibiotics are well documented and regarded as significant by clinicians. However, some of the other bacterial etiologies of acute pharyngitis may also carry the risk of complications when they are not appropriately treated. Both group C and group G streptococci cause sporadic and epidemic pharyngitis that is clin- ically indistinguishable from GAS in school age children and in adults (13-16). Early treatment may reduce the duration of symp- toms, limit spread to susceptible contacts, and prevent invasive infections (17, 18). A. haemolyticum causes pharyngitis primarily in adolescents and young adults presenting with clinical fea- tures that overlap those of GAS pharyngitis (11, 19, 20). Serious invasive infections caused by A. haemolyticum have been re- ported and include peritonsillar and pharyngeal abscesses, bacte- remia, and pneumonia (21, 22). The pathogenesis of F. necropho- rum invasive disease and its link to antecedent pharyngitis are clear. F. necrophorum causes most cases of Lemierre’s syndrome, which is characterized by necrotizing tonsillopharyngitis, fol- lowed by bacteremia, septic thrombophlebitis of the internal jug- ular vein, and septic pulmonary emboli. Additionally, there is ev- idence that F. necrophorum causes endemic pharyngitis in adolescents and young adults in the absence of Lemierre’s syn- drome at a rate similar to that of GAS, and on the basis of pub- lished epidemiologic data, F. necrophorum is estimated to cause Lemierre’s syndrome at a higher incidence than that at which GAS causes acute rheumatic fever (23, 24). It should be noted that evidence demonstrating if and/or how often pharyngitis caused by F. necrophorum directly leads to Lemierre’s syndrome and if treat- ment with antibiotic therapy would prevent it does not exist (25). Choosing a diagnostic test for acute pharyngitis. Despite the wide etiologic differential for acute pharyngitis, diagnostic testing for most patients is limited to methods that target GAS. The most commonly used diagnostic tests include bacterial culture, GAS antigen detection, and GAS nucleic acid amplification assays.
The main reasons to identify the causative organisms in cases of aseptic meningitis and encephalitis are (i) to provide a rational basis for chemotherapy and prognosis, (ii) to limit unnecessary investigations, and (iii) to provide epidemiological information. Conventional techniques of virus detection in ce- rebrospinal fluid (CSF) are often unsatisfactory. Virus isola- tion from CSF in cell culture is inefficient for most of the viruses that cause disease in the central nervous system (CNS). The exceptions are members of the enterovirus group, the echoviruses, polioviruses, and coxsackie B viruses. Virus isola- tion may, however, take up to 7 days. Circumstantial evidence of enteroviral infections can be gained from culture of throat swabs and stool specimens and from a rise in specific serum antibody titer in cases of herpes simplex virus (HSV) infection of the CNS. However, excretion of enteroviruses in stool spec- imens can continue for many weeks following an enteroviral infection, and the majority of these infections do not cause CNS or any other symptoms. Brain biopsy—perhaps the only existing “gold standard” in diagnosing viral encephalitis—is now rarely justified because of its invasive nature. Laboratory diagnoses of the other organisms included in this study, for example, JC virus (JCV) and toxoplasma, are also difficult by conventional means or are achieved slowly by serological re- sponse or isolation in infections with lymphocytic choriomen- ingitis virus (LCMV), borreliae, and mycobacteria. The slow- ness and the low sensitivities and (in some instances) specificities of these techniques severely limit their usefulness. Nucleic acid amplification techniques, such as PCR, have obvious advantages compared to conventional techniques: their sensitivities and specificities are unparalleled. Several studies in which PCR was applied to the diagnosis of CNS infections, especially those with HSV (14, 18) and enterovi-
A recent study compared nasopharyngeal swabbing with PorA-based immunohistochemical staining of tonsillar tissue for the detection of meningococcal carriage in 32 patients undergoing tonsillectomy (13) and concluded that swabbing detects only one-quarter of carriers and that carriage is more frequent than previously thought. As the tissue was diseased (necessitating removal) and the function of lymphoid tissue is to capture microorganisms, the detection of meningococci within the tonsillar material may not necessarily reflect car- riage or provide a reservoir of infection. However, porA may be a more appropriate target than ctrA for PCR-based detection of meningococcal carriage. In addition, porA PCR would en- able the determination of subcapsular antigens, which have been associated with the development of specific immunity (9). Characterization of strains by standard immunological methods showed the majority (20 of 23) to be nongroupable and the remaining 3 strains to be group W135. However, PCR for group B- and group C-specific DNA detected six genotype B strains, three of which were from samples from which non- groupable meningococci were isolated, suggesting that these organisms were potentially capsulate but were not expressing in the nasopharynx. The isolation of nongroupable and group W135 strains with the same subtype from the throat swab and gargle from an individual also suggests that capsule expression is variable, as reported elsewhere (1, 6). Although not specif- ically sought in this study (isolates were from standard single- colony subcultures), simultaneous carriage of multiple strains (differing in PorA subtype) was detected in one student. Such carriage could facilitate genetic transfer between strains and explain how organisms may change their capsules. This may have significant implications for immunization planning if an
culture (1, 5, 8). In contrast, the results of our study suggest that the LightCycler PCR assay is more sensitive than our standard culture method for detecting GAS in the throat swab samples of our patients. After discordant positive results for the LightCycler PCR and Directigen methods versus the re- sults of culture were reconciled by a review of the patient’s medical history, the LightCycler PCR detected more true- positive samples (n ⫽ 58) than either the Directigen method (n ⫽ 31) or culture (n ⫽ 55). This increase in sensitivity was statistically significant (P ⬍ 0.0001) for the LightCycler PCR versus the Directigen method but was not statistically signifi- cant for the LightCycler PCR versus culture (P ⫽ 0.5465). The enhanced detection of GAS by the LightCycler PCR may be related to both the inherent qualities of the real-time PCR assay and the DNA extraction technique used. In prior pro- spective clinical studies, we have consistently noted increases in sensitivities for assays that use the LightCycler PCR tech- nology compared to the sensitivities of standard culture meth- ods. These include assays for B. pertussis (219% increase) (20), herpes simplex virus (23% increase) (10), varicella-zoster virus (91% increase) (11), and cytomegalovirus (88% increase) (M. J. Espy and T. F. Smith, Abstr. 100th Gen. Meet. Am. Soc. Microbiol., abstr. C-62, 2000). As a result of these clinical studies we have replaced standard culture-based methods with LightCycler PCR assays for direct detection of these organisms from clinical samples. We assume that the enhanced sensitivity of the LightCycler PCR assay is related in part to the S.E.T.S., which is used to prepare the specimen. This centrifugation appliance effectively concentrates pharyngeal secretions from throat swabs. Although we did not study this, higher rates of detection of GAS may occur if the concentrate from a tube in the S.E.T.S. is cultured or tested by the Directigen rapid anti- gen immunoassay.
Direct culture of throat swabs remains the “gold standard” for laboratory detection of GAS because of its high sensitivity (90 to 95%) and ability to detect the presence of other much less common bacterial causes of pharyngitis (e.g., ⬃ 2% of cases may be due to large-colony group C Streptococcus and Arcanobacterium haemolyticum), use of this method results in delayed (24 to 72 h) result reporting (11, 15, 16). The existing guideline in our province recommends early detection of GAS using a culture-based method or equivalent (17). Our laboratory has used the Hologic GAS Direct (GASD) test for more than a decade because of its documented equivalence to culture while allowing for more rapid reporting of results (i.e., 24 h after specimen receipt versus 24 to 48 h for culture) (18, 19). It was of interest, however, to investigate replacement of our current method with a commercial real-time PCR test that potentially would offer improved detection performance and increased efﬁciency for analysis of the high volume of throat samples submitted to our laboratory (i.e., ⬎ 125,000 per year in 2015) so that same-day reporting of results was maintained. Several commercial real-time PCR assays have recently been licensed for detection of S. pyogenes from throat swabs. Although these assays provide a sensitivity and speciﬁcity comparable to that of culture, DNA extraction is commonly required prior to performing quantitative PCR (qPCR) (20–22). Both the Solana GAS (Quidel, San Diego, CA) and the cobas Liat GAS (Roche Molecular Diagnostics, Branchburg, NJ) assay systems were designed to either perform a small number of tests per run or a single test at point of care, respectively. The Simplexa GAS Direct qPCR assay was therefore evaluated because it was recently licensed by the Health Protection Branch (HPB) in Canada, does not require sample extraction, and is conducive to high-volume laboratory testing. Currently there is one reported evaluation of the Simplexa qPCR assay that was recently performed by the manufacturer (22). The performance of GASD was clinically and economically compared to the Simplexa Direct GAS real-time assay in our regional laboratory setting.