Importance of inoculum size and sampling effect in rapid antigen detectionfor diagnosis of Streptococcus pyogenes pharyngitis

Current recommendations suggest that negative rapid Streptococcus pyogenes antigen tests be backed up with a culture, reflecting evidence that culture may have a higher sensitivity and also that testing of a second swab may y ield a different (i.e., a positive) result because of variation in sample s ize or distribution. If the latter is common, the sensitivities of current antigen detection tests might be improved by simply increasing the amount o f sample tested. The present study assessed the effect of antigen testing o f two swabs extracted together compared to independent testing of each swab extracted separately for children with clinical pharyngitis. S. pyogenes g rew from one or both swabs for 198 (37%) of 537 children. The combined cult ure was significantly (P < 0.05) more sensitive than culture of either swab alone, Compared to combined culture, antigen testing of two swabs extracte d and tested together was significantly more sensitive than two single swab extractions (94.1 versus 80%; P = 0.03); however, the specificity was decr eased (81.5 versus 89.8 to 92.7%; P < 0.05), This study suggests that sampl e size and/or uneven sample distribution may have influenced the apparent s ensitivities of prior studies that compared antigen tests to a single plate culture. A strategy, such as the one used in the present study, that incre ases the sample size available for antigen testing (i.e., extraction of sam ples from both swabs) may improve detection rates to a level that will bett er approximate true disease status and obviate the need for backup cultures if specificity can be improved.