Study Area and Population:
The study was conducted in the children outpatient clinics of University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State, and Federal Medical Center, Umuahia, Abia State, both in Southeast Nigeria. The UNTH, is a tertiary health facility located at Ituku/Ozalla, Enugu State, Southeast Nigeria. Enugu State has a population of approximately 3.3 million people (Federal Republic of Nigeria Official Gazette, 2006)25, according to national census of 2006. The children under 14 years make up 41 percent of the entire population (Nigeria Demographic Profile 2012). 26 The UNTH is a government hospital that charges fees for services, with no form of subsidy to the out-patient or in-patient services. There are laboratories that carry out different investigations and pharmacy that dispense drugs.
Federal medical Center, Umuahia is a tertiary health institution located in Umuahia, the capital of Abia state. The children out-patient clinic of the hospital renders service 5 days in a week. The hospital has a well-equipped laboratories, among which is a microbiology laboratory.
The study was a combination of both retrospective and cross-sectional approach on cases of acute tonsillitis who presented to the clinic were recruited.
Sample size calculation.
The Epi-Info software was used to calculate the sample size. The Epi-Info version 7 (CDC)27 was used to estimate the minimum sample size. This was based on the input of the prevalence of childhood tonsillitis of 11% 28and 95% confidence interval and power of 80%. The subjects were consecutively recruited as they attend the clinics. The sample size would be calculated using the formula for bioequivalents and prevalence of acute tonsillits of 11%. N = Z2 (1-P)/d2 Where N = is the size of sample for each group of treatment, Z is 2 standard deviation = 1.96, P = prevalence of 0.26, d = level of statistical significance of 5% (0.05). Therefore, N = (1.96)2(1-0.11)/(0.05)2 = 140 children with either acute tonsillitis. To recruit the sample size, all the children that present to children out-patient clinics with fever, whose caregiver gave consent to be part of the study were recruited. A total of 172 children with either tonsillitis were recruited. The questionnaire was pre-tested and, ambiguous questions modified for clarity.
The medical records of children managed for either tonsillitis over the period of 5 years from January 2014 to December, 2019 were retrieved and reviewed. The information on their age, gender, place of resident, household sizes, presenting symptoms, health seeking behaviors and treatment received were documented in a questionnaire. Children with enlarged, inflamed and exudative tonsils, and or ear discharge, who presented to children out-patient clinics from March 2019 to September 2019 had their throat swab taken for microscopy, culture and sensitivity.
The oral cavity of the child was opened widely, illuminated adequately with a head lamp, and the tongue depressed with a sterile wooden specular. The sterile swab stick was rubbed firmly on the surfaces of the inflamed tonsils, avoiding contact with the tongue or buccal mucosal. The swab stick was used to inoculate the solid agar culture media (chocolate, blood and Mac-Conkey agar. The plates were incubated at 370C and observed for growth after 24 hours. The antibiotic susceptibility assay was conducted based on modified Kirby Bauer disc diffusion method on Mueller Hinton agar.22,29,30 The choice of antibiotics was based on commonly used antibiotics obtained from review of medical records and the feasible combination available in the antibiogram kit. Sensitivity was based on observed standard clearance around the antibiotic disc.31. Direct microscopy was done using the isolates from the culture media.32 The culture and sensitivity was done at the Microbiology laboratory of University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. The samples collected from Federal Medical Center, Umuahia, were put in ice pack and later refrigerated and sent in batches every 2 days (Wednesday and Fridays). Samples were not collected on Fridays, Saturdays and Sunday.
Data analysis. The data was entered and analyzed using SPSS version 20. Frequencies were calculated. Yates correction was used in variables with less than value of 0.05 to determine the significant.
The approval for the study was obtained from Health Research and Ethics Committee of University of Nigeria Teaching Hospital, Ituku-Ozalla. The Ethical Clearance Certificate number was NHREC/05/01/2008B-FWA00002458-1RB00002323. Issued on 1st April 2019. The Institutional reference number was UNTH/CSA/329/OL.5. All methods were performed in accordance with the relevant guidelines and regulations as described in the Helsinki Declaration. Information about the study was explained to the parents/caregivers of these children and written informed consent was obtained before recruiting them into the study. The results of the swab microscopy and sensitivity were held in confidentiality. The children were commenced on empirical antibiotics, which were later reviewed with the sensitivity results for the positive isolates.