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Antibiotic susceptibility of Group A Streptococcus isolated from throat
swab culture of school children in Pokhara, Nepal
KR Rijal,1 N Dhakal,1 RC Shah,1 S Timilsina,1 P Mahato,1 S Thapa2 and P Ghimire2
1The School of Pharmaceutical and Biomedical Sciences, Pokhara University, 2Central Department of Microbiology, Tribhuvan University
Komal Raj Rijal,
Lecturer, Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu,
ABSTRACTGroup A Streptococcus (GAS) or Streptococcus pyogenes
is estimated to be present in 5.0-15.0% of normalindividual in the respiratory tract, vagina, skin and anus without any sign of disease. This study was carried outto find out the rate of asymptomatic throat carriage of S. pyogenes
and antibiotic susceptibility of the isolatesin school children of Pokhara, Western Nepal. A total of 487 randomly selected children younger than 16 yearswere included in the study. Throat swabs collected were subjected to 5.0% Sheep blood agar supplementedwith crystal violet (CVBA).GAS was identified by â-haemolytic colonies, bacitracin sensitivity, cotrimoxazoleresistivity, catalase negativity and PYR positivity. Antibiotic susceptibility test was performed on Muller Hintonagar (MHA) containing 5% sheep blood by modified Kirby-Bauer disc diffusion method. Out of total 487throat swabs, GAS was isolated in 9.2% ( n=45). Among the isolates, 46.6% (n=21) were from male childrenwhere as 53.4% (n=24) from female children. There was no significant sex difference in colonization of GAS(p>0.05). Out of 45 isolates, 100.0% isolates were sensitive to antibiotic penicillin-G and amoxycillin where as15.6%, 6.6%, and 2.2% isolates were resistant to antibiotic erythromycin, tetracycline and azithromycinrespectively.
GAS, CVBA, â-haemolytic, modified kirby-bauer method.
moreover, such programs are not even in the row. Little
Group A Streptococcus (GAS) consists of a single
information is known about the prevalence of S.
species, Streptococcus pyogenes
.1 It belongs to
from the throat swab of school children in
Lancefield group A and is beta-hemolytic, hence called
Nepal. So, this study was performed outside Kathmandu
Group A beta-hemolytic Streptococci (GABHS).2
valley at Western Region, Pokhara. This study provides
Streptococcal carriage bas been defined as the recovery
information on prevalence, distribution and antibiotic
of GAS from the nasopharynx or oropharynx in the
susceptibility pattern of S. pyogenes
absence of any evidence of acute infection.3 Thepathogenesis of GAS is mediated by a variety of factors.
One of them is Streptolysin ‘O’ toxin, which damages
cell membranes and accounts for the hemolysis
Throat swabs of 487 school children within age limit of
demonstrated on sheep blood agar.1 Disease spectrum
5-16 years were collected for the purpose of the study
of Group A Streptococcus (GAS) or S. pyogenes
during June to October 2008. The specimens were
from mild infectious as pharyngitis, tonsilitis and
collected with the help of sterile throat swabs available
impetigo to life threatening infections like necrotizing
commercially. The swab was rubbed with rotation over
fascititis and toxic-shock like syndrome. These are often
one tonsilar area, then the arch of the soft palate anduvula, the other tonsilar area and finally the posterior
followed by post infective sequelae of rheumatic fever,
pharyngeal wall. Each sample was labeled with code
rheumatic heart disease and post streptococcal acute
number and various other information including age, sex,
glomerulonephritis.4 GAS infection is ordinarily spread
location etc were also recorded. The sample was
by direct person-to-person contact, most likely via drops
transported to the laboratory of the School of
of saliva, nasal secretions, contaminated fingers, dust
Pharmaceutical and Biomedical sciences in sterile
or fomites.5 All beta-hemolytic Group A Streptococcus
condition within 1-2 hours for processing as have been
are sensitive to penicillin G, and most are sensitive to
erythromycin. A high frequency of resistance toerythromycin in GAS has been reported, particularly in
countries where antibiotics are overused.6 In Nepal
The throat swab was rubbed, while being rotated over a
control programs for streptococci does not exist,
large well area about one third of the surface on a blood
Isolation of S. pyogenes
from school children
agar plate and the well was streaked out with a loop over
pharyngitis. The condition is most prevalent in the age
the remainder of the plate. The plate was incubated at
group of 5 to 15 years, the highest prevalence occuring
370C for 24 hours in candle jar. S. pyogenes
in 7 years old children and rarely occuring in those under
beta-hemolytic colonies i.e. the colonies were surrounded
3 years of age. Males are equally affected by GABHS
by a zone of complete hemolysis with decolorization of
as females. GABHS frequently colonizes the pharynx
the hemoglobin. The suspected colony taken out from
of asymptomatic individuals, as 15.0%-20.0% of school-
primary culture on blood agar plates, were subcultured
age children are asymptomatic carriers. In our study,
on crystal violet blood agar plate by placing a bacitracin
9.2% of school children were colonized by GAS in their
disc (0.05units) over initial streaked area and
throat. Similar study done by Tavakkoli et al
cotrimoxazole disc in secondary streaked area and
the prevalence of carriers among primary school children
incubated at 370C for 24 hours supplemented with 5-10%
was 4.9%. Bogovac et al
11 reported 6.0% prevalence in
CO . â−haemolytic colonies showing bacitracin sensitivity,
all age groups and 11.7% prevalence in 6-13 years old
cotrimoxozole resistivity on CVBA was further identified
children from Croatia. Durmaz et al
12 showed the
by gram staining, catalase test and PYR test.9
prevalence of S. pyogenes
nasopharyngeal carriage in14.3% healthy school children and children in an
Antibiotic susceptibility test
orphanage in Turkey. The study done in Pittisburgh,
All the identified GAS isolates from throat swabs were
Pennsylvania reported the prevalence of carriage of
subjected to in-vitro susceptibility test by modified
group A streptococci in school children to be 27.0-
Kirby-Bauer disc diffusion method. The antibiotics used
32.0%.13 The isolation rate of GAS was 25.9% according
in the study were tetracycline (30µg), erythromycin
to Ozturk et al
1 in asymptomatic school children in the
(15µg), cephalexin (30µg), penicillin-G (10µg),
gentamycin (10µg), ciprofloxacin (5 µg), amoxicillin(30 µg) and azithromycin(15µg).
In our study, the frequency of GAS was similar in allage groups of school children, but it was slightly higher
in children aged 5-8 years. The study done by Durmaz
Among 487 school children, 243 (49.9%) were male
12 in Turkey, showed that the rates of carriers for
and 244 (50.1%) were female. Out of 487 throat swabs
boys and girls were similar and the frequency was similar
studied, S. pyogenes
isolated from 45 samples
in all age groups of school children, but it was
(9.2%). Among the isolates, 21 (46.6%) were from male
significantly higher in children aged 4-6 years living in
whereas 24 (53.4%) were from female. There was no
significant sex difference in colonization of S. pyogenes
Macrolides including erythromycin and clindamycin
Highest colonization of S. pyogenes
have been widely used for treatment of acute pharyngitis
in the age group 5-8 years (11.8%) (Table-1).
and invasive infection of GAS respectively. Kim et al
isolates indicated a relative high rate of
recently reported a high frequency of resistance to
resistance towards erythromycin (15.6%) followed by
erythromycin in GAS, particularly in countries where
tetracycline (6.6%) and azithromycin (2.2%). According
antibiotics are overused.
Of all throat isolates, 95.0%
to our study, penicillin G and amoxicillin showed 100%
were predominantly resistant to erythromycin, 70.0%
sensitivity towards the isolates (Table-2).
to clindamycin, 56.0% to azithromycin and 24.0% toclarithromycin according to the study done in Sindh.14
Tamayo et al
15 reported the erythromycin resistance rate
Group A beta Hemolytic Streptococci (GABHS) is
to be 21.7% in the study done in Spain in 2004. Ciftci
among the most prevalent bacterial childhood infection
16 reported resistance to erythromycin,
and constitutes 20.0%-40.0% of all cases of exudative
clarithromycin, azithromycin and clindamycin as 3.8%,
Antibiotic susceptibility pattern of S. pyogenes isolates from throat swabs
5.2%, 4.2% and 3.0% respectively. Alberti et al
6. Kim S, Lee NY. Epidemiology and Antibiotic Resistance of
increased resistance of S. pyogenes
to ciprofloxacin in
Group A Streptococcus Isolated from Healthy School Childrenin Korea. J Antimicrob Chemother
2004; 54: 447-50.
Spain at the highest rate ever published and it is 63.3%.
7. Forbes BA, Sahm DF, Weissfield AS. Bailey and Scott’s
Of all the isolates analyzed in our study, 15.6% were
(11th ed.), Mosby Publisher, 2002.
resistant to erythromycin, 6.6% to tetracycline and 2.2%
8. Collee JG, Marmion BP, Fraser AG et al
. Mackie and
to azithromycin. All the isolates were sensitive to beta
McCartney Practical Medical Microbiology, (14th ed.),
lactam antibiotics (penicillin and amoxycillin). In a large
Churchill Living stone, United Kingdom, 1996.
survey done in Iran by Jasir et al
18 found no penicillin
9. Vandepitte J, Verhaegen J, Engbaek K et al
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Procedures in Clinical Bacteriology, (2nd ed.), WHO, 2004.
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and only a few
10. Tavakkoli A, Irajian GR and Farshad S. Determination of the
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frequency carrier of Streptococcus pyogenes
in some of the girls
France by Binjen et al
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1998; 16: 33–9.
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A Streptococcal carriers in asymptomatic children and clonal
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