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The utility of rapid antigen detection testing for the diagnosis of streptococcal
pharyngitis in low-resource settings
Anne W. Rimoin a,*, Christa L. Fischer Walker b, Hala S. Hamza c, Nevine Elminawi d,
Hadeer Abdel Ghafar c, Adriana Vince e, Antonia L.A. da Cunha f, Shamim Qazi g, Dace Gardovska h,
Mark C. Steinhoff b,i
a
Department of Epidemiology, UCLA School of Public Health, 650 Charles E. Young Drive S, CHS 41-275, Los Angeles, CA 90095, USA
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
c
Department of Pediatrics, University of Cairo, Egypt
d
Fayoum University, Cairo, Egypt
e
Department of Infectology, Zagreb Medical School/Department of Viral Hepatitis, University Hospital for Infectious Diseases, Zagreb, Croatia
f
Department of Pediatrics, Federal University of Rio de Janeiro, Brazil
g
Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland
h
Department of Pediatrics, Riga Stradins University and Childrens University Hospital, Riga, Latvia
i
Childrens Global Health Center, Cincinnati Childrens Hospital, Cincinnati, OH, USA
b
A R T I C L E I N F O
S U M M A R Y
Article history:
Received 16 October 2009
Objectives: To evaluate the utility of rapid antigen detection testing (RADT) for the diagnosis of group A
streptococcal (GAS) pharyngitis in pediatric outpatient clinics in four countries with varied socioeconomic and geographic proles.
Methods: We prospectively evaluated the utility of a commercial RADT in children aged 212 years
presenting with symptoms of pharyngitis to urban outpatient clinics in Brazil, Croatia, Egypt, and
Latvia between August 2001 and December 2005. We compared the performance of the RADT to culture
using diagnostic and agreement statistics, including sensitivity, specicity, and positive and negative
predictive values. The Centor scores for GAS diagnosis were used to assess the potential effect of
spectrum bias on RADT results.
Results: Two thousand four hundred and seventy-two children were enrolled at four sites. The
prevalence of GAS by throat culture varied by country (range 24.539.4%) and by RADT (range 23.9
41.8%). Compared to culture, RADT sensitivity ranged from 72.4% to 91.8% and specicity ranged from
85.7% to 96.4%. The positive predictive value ranged from 67.9% to 88.6% and negative predictive value
ranged from 88.1% to 95.7%.
Conclusions: In limited-resource regions where microbiological diagnosis is not feasible or practical,
RADTs should be considered an option that can be performed in a clinic and provide timely results.
2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
1. Introduction
Group A beta-hemolytic streptococcal (GAS) pharyngitis is a
common illness in children and the most common bacterial cause
of acute pharyngitis worldwide. In afuent countries, the nonsuppurative sequelae of untreated GAS pharyngitis including acute
rheumatic fever (ARF) and rheumatic heart disease (RHD) are now
rare. However, in regions with limited resources, ARF and RHD are
still signicant causes of morbidity and mortality, with prevalence
rates that range from 1 to 5 per 1000 school-aged children, leading
* Corresponding author.
E-mail address: arimoin@ucla.edu (A.W. Rimoin).
1201-9712/$36.00 see front matter 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijid.2010.02.2269
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Table 1
Comparisons of clinical and demographic characteristics by country
All sites
Brazil
Croatia
Egypt
Latvia
2472
5.2 0.05
1070 (43.3)
184
5.8 0.21
95 (51.6)
404
5.8 0.14
169 (41.8)
1626
4.8 0.06
687 (42.3)
258
6.6 1.9
119 (46.1)
1997 (80.8)
1037 (41.9)
753 (30.5)
686 (27.8)
162 (88.0)
80 (43.5)
52 (28.3)
52 (28.3)
257
239
155
158
1348 (82.9)
540 (33.2)
385 (23.7)
291 (17.9)
230
178
161
185
(63.6)
(59.2)
(38.4)
(39.1)
(89.1)
(69.0)
(62.4)
(71.7)
the other sites due to the large size of the outpatient clinic and the
experience of the local staff in conducting large clinical studies.
Each study site enrolled patients for at least one full calendar year.
Patient demographic and clinical characteristics varied across
study sites and are shown in Table 1. The mean age of patients
across sites ranged from 4.8 years in Egypt to 6.6 years in Latvia
(p < 0.001).
Table 2 presents microbiological ndings and the performance
measures of the RADT as compared to throat culture at each study
site. The proportion of children with a positive GAS throat culture
Table 2
Comparisons of microbiological ndings among countries
Brazil (n = 184)
Croatia (n = 404)
Egypt (n = 1626)
Latvia (n = 258)
44 (23.9)
45 (24.5)
169 (41.8)
159 (39.4)
403 (24.8)
430 (26.4)
81 (31.4)
76 (29.5)
5 (2.7)
6 (3.3)
23 (5.7)
13 (3.2)
82 (5.0)
109 (6.7)
26 (10.1)
21 (8.1)
39 (21.2)
134 (72.8)
146 (36.1)
222 (55.0)
321 (19.7)
1114 (68.5)
55 (21.3)
156 (60.5)
86.7
96.4
88.6
95.7
3.33
91.8
90.6
86.4
94.5
0.89
74.7
93.1
79.7
91.1
2.97
72.4
85.7
67.9
88.1
3.10
(73.294.9)
(91.898.8)
(75.496.2)
(90.998.4)
(86.495.6)
(86.294.0)
(80.391.2)
(90.797.7)
(70.378.7)
(91.694.5)
(75.483.5)
(89.392.6)
(60.982.0)
(79.890.5)
(56.677.8)
(82.492.5)
OIA MAX, STREP A OIA MAX test; PPV, positive predictive value; NPV, negative predictive value; CI, condence interval; RADT, rapid antigen detection test.
a
The results of RADT and cultures were discordant in the same patient.
b
The results of RADT and cultures were concordant in the same patient.
Table 3
Association between clinical factors and detection of GAS pharyngitis by culture or RADT
Brazil
History of fever
Absence of cough
Pharyngeal or tonsillar exudates
Cervical lymphadenopathy
Croatia
History of fever
Absence of cough
Pharyngeal or tonsillar exudates
Cervical lymphadenopathy
Egypt
History of fever
Absence of cough
Pharyngeal or tonsillar exudates
Cervical lymphadenopathy
Latvia
History of fever
Absence of cough
Pharyngeal or tonsillar exudates
Cervical lymphadenopathy
162
80
52
52
41
30
24
26
42
33
25
23
257
239
155
156
94 (36.6)
110 (46.0)a
62 (40)
76 (48.7)a
101 (39.3)
111 (46.4)a
69 (44.5)
79 (50.6)a
1348
540
385
291
361 (26.8)
430 (79.6)a
121 (31.4)a
96 (33.0)a
341
173
123
106
230
178
161
185
67
51
48
59
73
57
47
59
(25.3)
(37.5)a
(46.2)a
(50)a
(29.1)
(28.7)
(29.8)
(31.9)a
GAS, group A Streptococcus; RADT, rapid antigen detection test; OIA MAX, STREP A OIA MAX test.
Results are n (%).
a
Statistically signicant, p 0.05.
(25.9)
(41.2)a
(48.1)
(44.2)a
(25.3)
(32.0)a
(31.9)a
(36.4)a
(31.7)
(32.0)
(29.2)
(31.9)
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Table 4
Sensitivity and negative predictive values of RADT as stratied by the Centor criteria scoresa
Centor score
Brazil (n = 184)
No. of patients (% total)
Positive OIA MAX, n (%)
Positive cultures, n (%)
Sensitivity, % (95% CI)
NPV, % (95% CI)
Croatia (n = 404)
No. of patients (%)
Positive OIA MAX, n (%)
Positive cultures, n (%)
Sensitivity, % (95% CI)
NPV, % (95% CI)
Egypt (n = 1626)
No. of patients (%)
Positive OIA MAX, n (%)
Positive cultures, n (%)
Sensitivity, % (95% CI)
NPV, % (95% CI)
Latvia (n = 258)
No. of patients (%)
Positive OIA MAX, n (%)
Positive cultures, n (%)
Sensitivity, % (95% CI)
NPV, % (95% CI)
10 (5.4)
0 (0)
0 (0)
68 (37.0)
5 (7.3)
7 (10.3)
42.9 (9.981.6)
93.7 (84.598.2)
58 (31.5)
11 (19.0)
12 (20.7)
83.3 (51.697.9)
95.7 (85.599.5)
30 (16.3)
16 (53.3)
14 (46.7)
100 (76.8100)
100 (76.8100)
18 (9.8)
12 (66.7)
12 (66.7)
100 (73.5100)
100 (54.1100)
28 (6.9)
10 (35.7)
8 (28.6)
100 (63.1100)
100 (81.5100)
98 (24.3)
34 (34.7)
29 (29.6)
93.1 (77.299.2)
89.9 (80.295.8)
151 (37.4)
64 (42.4)
66 (43.7)
87.9 (77.594.6)
90.8 (82.795.9)
101 (25)
46 (45.5)
43 (42.6)
93.0 (80.998.5)
94.5 (84.998.9)
26 (6.4)
15 (57.7)
13 (50)
100 (75.3100)
100 (71.5100)
138 (8.5)
25 (18.1)
29 (21.0)
69.0 (49.284.7)
92.0 (85.496.3)
725 (44.6)
142 (19.6)
164 (22.6)
72.0 (64.478.7)
92.1 (89.694.2)
504 (31.0)
134 (26.6)
364 (72.2)
73.4 (65.280.5)
90.0 (86.492.8)
205 (12.6)
75 (36.6)
80 (39.0)
80.0 (69.688.1)
87.7 (80.892.8)
54 (3.3)
27 (50)
18 (33.3)
94.4 (72.799.9)
96.3 (81.099.9)
3 (1.2)
1 (33.3)
1 (33.3)
100 (2.5100)
100 (15.8100)
34 (13.2)
8 (23.5)
9 (26.5)
55.6 (21.286.3)
84.6 (65.195.6)
95 (36.8)
33 (34.7)
28 (29.5)
78.6 (59.091.7)
90.3 (80.196.4)
112 (43.4)
36 (32.1)
34 (30.4)
70.6 (52.584.9)
86.8 (77.193.5)
14 (5.4)
3 (21.4)
4 (28.6)
75 (19.499.4)
90.9 (58.799.8)
RADT, rapid antigen detection test; OIA MAX, STREP A OIA MAX test; NPV, negative predictive value; CI, condence interval.
a
Centor criteria are history of fever, absence of cough, presence of pharyngeal or tonsillar exudates, and presence of cervical lymphadenopathy.
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