Tonsillitis has considerably a negative impact on the patients’ quality of life and has a significant burden on public health. Untreated childhood tonsillitis can leads to peritonsillar abscess, tonsillar stones, and rheumatic fever. Therefore, identification and antimicrobial susceptibility of bacterial causes of tonsillitis is essential to curtail for the treatment of tonsillitis. However, patients with tonsillitis managed empirically in health care’s settings of Somaliland. Therefore, this study presents the first report of the prevalence of culture confirmed bacterial tonsillitis and the antimicrobial resistance profiles of isolates in HGH.
In this study, 32.1% of children within five years of age had culture confirmed bacterial causes of tonsillitis. Due to the lack of previous data in Somaliland, comparison of countrywide results was not possible. However, the prevailing magnitude of tonsillitis is higher than similar studies with a prevalence of 11.3% in Ethiopia , 20.6% in Tanzania , 21.6% in Norway , and 19% in Bangladesh . On the other hand, the existing prevalence of bacterial causes of tonsillitis from this study was lower than studies done in the United Kingdom (79%) , Trinidad (62.5%) , India (72%) , Saudi Arabia (65%) , Benin (73.97%) and Ethiopia (51%) . The lower rate of bacterial tonsillitis in the present study compared to other developing countries might be attributed to differences in geography, community living status and hygienic practices, host factor and educational level of the parents.
The prevalence of bacterial causes of tonsillitis in children within five years of age was higher in males than in females which is similar to studies from India  and Nigeria. The variations on the percentage of tonsillitis between genders of the children could be due to the fact that males spend more time in outdoor than females. The percentage of tonsillitis was higher among children living in urban than rural areas. This was similar with studies done in India , and Ethiopia . This might be due to variation in: encountering infected people, exposure with air pollution from biofuel use, schooling and house crowding.
High rate of bacterial tonsillitis was reported among patients symptomatic for chronic (57.7%) and recurrent tonsillar infections (51.2%). These are indications of antimicrobial resistance and tonsillectomy. Regarding the prevalence of bacterial isolates; Streptococcus pyogenes was the most frequent bacterial isolate from children with tonsillitis in this study and its percentage (55%) is similar with studies in Ohio (58%) , Italy (69%) , and Trinidad (82.2%) . However, it is higher than studies from Egypt (17%) , Iran (20%), Iraq (29.7%), India (22.25%) , Saudi Arabia (40%), and Ethiopia (12.2%) . This variation might be influenced by climate changes, age and geographical inhabitation of the study participants.
In the present study, Staphylococcus aureus was the second most frequent isolate of bacterial causes of tonsillitis with a rate of 29%. This could be due to the persistence of S. aureus in the tonsillar tissues, treatment with antimicrobials and antibiotic resistance. Moreover, S. aureus has the potential to form biofilm which results recurrent and chronic infection as well as treatment failure. The isolation of S. aureus as the main agent of tonsillitis has been reported by several authors in Ethiopia , Brazil (40%) , Trinidad (68.9%) , and Nigeria (32.1%) .
It is a fact that isolation of S. pneumoniae indicates the existence of recurrent tonsillitis in children. The percentage (7%) of Streptococcus pneumoniae isolates from children with tonsillitis in the present study is lower than studies done from Poland (14%) , Belgium (21%) , Italy (4%) , and South Ethiopia (62.5%) . However, it was higher than studies done in the US (3.5%) , Nepal (4%)  and Nigeria (3.3%) . The percentage (4%) of Klebsiella pneumoniae causing tonsillitis in this study is higher than a study done in Brazil (1.4%) , but was lower than studies done in Singapore (6.6%) , Indonesia (7%). In this study, the prevalence of Moraxella catarrhalis was 3% which is different from studies done in the USA (22%) , Brazil (28.5%) , Denmark (53%) , Tanzania (90.8%) , and Ethiopia (12.3%) .
In the present study, there is high proportion of mixed infections particularly with S. pyogenes and S. aureus, S. pneumoniae and S. aureus and S. pneumoniae and M. catarrhalis. These co-infections of the tonsils may contribute to the severe inflammatory process and the failure of penicillin and ampicillin therapy which finally results recurrent infection, tonsillectomy, rheumatic fever and other complications [34, 38].
In this study, the percentage of Methicillin Resistant S. aureus (MRSA) isolates among children with tonsillitis was 15.8%. This is higher than studies done in Germany (0.8%) , Lahore (5.5%) , Japan (0.8%) , Brazil (3.3%)  and Ethiopia (2.3%) , but lower than studies done in the USA (16%) , Benin (17.95%)  and Uganda (32%) . The variation between the studies might be due to geographical variations, age and child contact to hospitalized patients who could have contracted the MRSA from hospitals.
The resistance of the isolates to ampicillin was 91.6% and 14.7% to the association of amoxicillin and clavulanate. The higher resistance to ampicillin by all of the bacterial isolates might be due to production of beta lactamase enzyme as well as abuse and excessive use of cheap drugs, which can be afforded and administered without a physician’s guidance. This is a major concern that limits the use of this common therapeutic option in clinical practice in developing countries. The rate of penicillin resistance is comparable with reports from Nigeria (100%) .
The resistance rate of 94.9% of S. pyogenes to ampicillin is worrisome. As B -lactam antibiotics are the drug of choice for strep throat. The percentage of S. pyogenes resistant to gentamicin (42.3%) and ofloxacin (43.6%) in the present study was comparable to studies done in Iran (32.2%) . The resistance of Streptococcus pyogenes to the above drugs might be due to the enzymatic inactivation mediated by aminoglycoside-modifying enzymes (AMEs), and point mutations in the quinolones resistance-determining region (QRDR).
The resistance of S. aureus to ciprofloxacin (35.7%) in this study, was lower than studies done in Egypt (90.9%)  and Nepal (100%) , but was higher than studies done in Brazil (24.6%) . On the other hand, the resistance profile of S. pneumoniae to erythromycin (30%) is similar to a study done in Malaysia, with a rate of (30%) but different from studies done in China (56%, 20%) , Lithuania (78.8%)  and Ethiopia (12.4%) .
One of the major worries when determining resistance profiles of isolates is the availability of MDR strains. In this study, half of the bacterial isolates were MDR. This is a series problem for children within five years of age in Somaliland. Children involved in the study area were outpatients and they might have constant contact with other children and their family. Moreover, in the study area there is no routine culture and antimicrobial susceptibility testing and management of children with tonsillitis is empirical. These may results repeated infections of the tonsils, pyogenic meningitis, rheumatic fever, lower respiratory tract infections and difficulty to select the effective antibiotics. Furthermore, existence of MDR isolates demonstrates persistence of the bacteria and possibility of antimicrobial resistance dissemination and recurrence of infection .
The percentage of MDR S. pneumoniae (60%) in this study was higher than studies from Poland (52.9%) , Lithuania (12.5%)  and Vietnam (35%) . In this study, all isolates of Pseudomonas aeruginosa were MDR (100%) which is concurrent to a study in Brazil (100%) . These high proportions of MDR among the isolates might be due to productions of beta-lactamase enzyme by Pseudomonas aeruginosa and production of Penicillin binding proteins in Streptococcus pneumoniae.
In the present study, difficulty of swallowing is one of the predictors of bacterial tonsillitis in children within five years of age. Similar findings were reported in India  and Lithuania (48). History of tonsillitis was also a predictor variable in this study which was similar to studies done in Ethiopia , and Yemen . These might be due to cohabitations of the tonsils by multiple bacterial isolates as depicted in Table 4 and failure of penicillin and ampicillin therapy.
Weight loss was also another predictor for bacterial tonsillitis in this study in which similar studies were reported in Iran , and Germany . Furthermore, attending school was a risk factor for tonsillitis in this study similar to studies done in Uganda , and Australia . This might be due to overcrowding during schooling among children where carrier children can easily interact with healthy children.