Clinical predictors of childhood streptococcal pharyngitis

  • Rulifa Syahroel
  • Amrin Alkamar
  • A. Aziz Djamal
  • Rizanda Machmud
Keywords: acute pharyngitis, GABHS, pharyngeal swab culture, clinical predictors


Background Antibiotic prescription for the management of all acute
pharyngitis seems to be increasing recently. Streptococcal pharyngitis
is the one that has strong indication for antibiotic prescription. It
is quiet hard to distinguish the clinical features of streptococcal
pharyngitis from non-streptococcal one.
Objective To determine specifically clinical features of streptococcal
pharyngitis and distinguish them from non-streptococcal one.
Methods We conducted a cross-sectional study on children with
acute pharyngitis at Pediatric Outpatient Department Dr. M.
Djamil Hospital, Padang from November 2006 until March 2007.
Data on clinical features and pharyngeal swab culture results were
analyzed using chi-square test for clinical predictors. All were then
reanalyzed using multivariate logistic regression.
Results Ninety-five children aged 3-13 years were enrolled and
pharyngeal swab culture was performed. Group A β -haemolyticus
streptococcus was found in 13 children (14%). Absence of cough,
sore throat, tonsillar exudates and tender anterior cervical
adenopathy were the clinical predictors for streptococcal
pharyngitis and the last two shared highest risk (OR 55.05;
31.82). Combination of tonsillar exudates, tender anterior cervical
adenopathy and absence of cough contributed 99,3% probability.
Conclusions Streptococcal pharyngitis includes a small part of all
childhood with acute pharyngitis. High grade fever, sore throat,
absence of cough, tonsiller excudates and tender anterior cervical
adenopathy were considered as clinical predictors for childhood
streptococcal pharygitis. Combination of some clinical predictors
will strengthen the probability of streptococcal pharyngitis.

Author Biographies

Rulifa Syahroel
Department of Child Health, Medical School, Andalas
University, Padang, Indonesia
Amrin Alkamar
Department of Child Health, Medical School, Andalas
University, Padang, Indonesia
A. Aziz Djamal
Department of Clinical Microbiology, Medical School, Andalas University, Padang, Indonesia
Rizanda Machmud
Department of Public Health/ Preventive Medicine, Medical
School, Andalas University, Padang, Indonesia


1. Smeesters PR, Campos D, Van Melderon L, de Agular E,
Vanderpas J, Vergison A. Pharyngitis in low resource set-
ting: A pragmatic clinical approach to reduce unnecessary
antibiotic use. Pediatrics 2006;118:1607-11.
2. Schwartz B, Marcy M, Phillips WR, Gerber MA, Dowell
SF. Pharyngitis. Principles of judicious use of anti microbial
agents. Pediatrics 1998;101:171-4.
3. Vincent MT, Celestin N, Hussain AN. Pharyngitis. Am Fam
Physician 2004;69:1465-70.
4. Dowell SF, Schwartz B, Phillips WR. Appropriate use of an-
tibiotics for URIs in children: Part II. Cough, pharyngitis and
the common cold. Am Fam Physician 1998;58:1335-47.
5. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial
prescribing rates for children and adolescents. JAMA 2002;
6. Rossenstein N, Phillips WR, Gerber MA, Marcy SM, Scwartz
B, Dowell SF. The common cold. Principles of judicious use
of antimicrobial agents. Pediatrics 1998;101:181-4.
7. Bisno AL, Kaplan EL. Appropriate use of antibiotics. Phar-
yngitis. Ann Intern Med 2002;136:489-90.
8. Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH.
Practice guidelines for diagnosis and management of group A
streptococcal pharyngitis. Clin Infect Dis 2002;35:113-25.
9. American Academy of Pediatrics. Group A streptococcal in-
fection. In: Pickering L, editor. Red Book 2003. Report of the
Committee on Infectious Disease, 26th ed. Elk Grove Village,
IL: American Academy of Pediatrics;2003: p. 576-8.
10. Pichichero ME. Group A beta-hemolytic streptococcal infec-
tions. Pediatr Rev 1998;19:291-303.
11. Hayes CS, Williamson H Jr. Management of group A beta-
hemolytic streptococcal pharyngitis. Am Fam Physician
12. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical
score to reduce unnecessary antibiotic use in patients with
sore throat. Can Med Assoc J 1998;158:75-83.
13. Bisno AL. Acute pharyngitis. N Engl J Med 2001;344:205-11.
14. Chi H, Chiu NC, Li WC, Huang FY. Etiology of acute phar-
yngitis in children: Is antibiotic needed? J Microbiol Immunol
Infect 2003;36:26-30.
15. Rimoin AW, Hamza HS, Vince A, Kumar R, daCunha ALA,
Walker CF, et al. Evaluation of the WHO clinical decision rule
for streptococcal pharyngitis. Arch Dis Child 2005;90:1066-70.
16. Lin MH, Fong WK, Chang PF, Yen CW, Huang KL, Lin
SJ. Predictive value of clinical features in differentiating
group A β-hemolytic streptococcal pharyngitis in children.
J Microbiol Immunol Infect 2003;36:21-5.
17. Hamza H. Group A streptococcal pharyngitis (GRASP)
study. Available from: URL:
18. Park SY, Gerber MA, Tanz RR, Hickner JM, Galliher JM,
Chuang I, et al. Clinicians’ management of children and
adolescents with acute pharyngitis. Pediatrics 2006;117:
19. Martin JM, Green M, Barbadora KA, Wald ER. Group A strep-
tococci among school-aged children. Clinical characteristic and
the carrier state. Pediatrics 2004;114:1212-9.
20. Sahin F, Ulukol B, Aysef D, Suskan E. The validity of di-
agnostic criteria for streptococcal pharyngitis in integrated
management of childhood illness (IMCI) guidelines. J Trop
Pediatr 2003;49:377-9.
21. Nandi S, Kumar R, Ray P, Vohra H, Ganguly NK. Group
A streptococcal sore throat in a periurban population of
northern India: A one year prospective study. Bull World
Health Organ 2001;79:528-33.
22. Ruppert SD. Differential diagnosis of common causes of
pediatric pharyngitis. Nurse Pract 1996;21:38-48.
23. Bourbeau PP. Role of the microbiology laboratory in diagnosis
and management of pharyngitis. Minireview. J Clin Microbiol
24. Hall MC, Kieke B, Gonzales R, Belongia EA. Spectrum
bias of rapid antigen detection test for group A β-hemolytic
streptococcal pharyngitis in a pediatric population. Pediatrics
25. Van Limbergen J, Kalima P, Taheri S, Beattie TF. Strepto-
coccus A in pediatric accident and emergency: Are rapid
streptococcal tests and clinical examination of any help?
Emerg Med J 2006;23:32-4.
26. dos Santos AG, Berezin EN. Comparative analysis of clinical
and laboratory methods for diagnosing streptococcal sore
throat. J Pediatr (Rio J) 2005;81:23-8.
27. Sauver JLS, Weaver AL, Orvidas LJ, Jacobson RM, Jacob-
sen SJ. Population-based prevalence of repeated group A
β-hemolytic streptococcal pharyngitis episodes. Mayo Clin
Proc 2006;81:1172-6.
28. Attia M, Zaoutis T, Eppes S, Klein J, Meier F. Multivariate
predictive models for group A β-hemolytic streptococcal
pharyngitis in children. Acad Emerg Med 1999;6:8-13.
29. Nawaz H, Smith DS, Mazhari R, Katz DL. Concordance
of clinical findings and clinical judgement in the diag-
nosis of streptococcal pharyngitis. Acad Emerg Med
30. DiMatteo LA, Lowenstein SR, Brimhall B, Reiquam W,
Gonzales R. The relationship between the clinical features of
pharyngitis and the sensitivity of a rapid antigen test: Evidence
of spectrum bias. Ann Emerg Med 2001;38:658-52.
31. Thompson LDR, Wenig BM, Kornblut AD. Pharyngitis.
In: Bailey BJ, Healy GB, Johnson JT, Jackler RK, Calhoum
KH, Pillbury HC, Tardy ME, editors. Head & neck surgery-
otolaryngology, 3rd ed. Philadelphia: Lippincott Williams &
Wilkins; 2001. p. 543-54.
How to Cite
Syahroel R, Alkamar A, Djamal A, Machmud R. Clinical predictors of childhood streptococcal pharyngitis. PI [Internet]. 1May2008 [cited 14Jun.2024];48(2):114-. Available from:
Received 2016-09-07
Accepted 2016-09-07
Published 2008-05-01