Authors: Kefiyalew Mihrete, Tewachew Awoke, Addisu Melake, Tadese Sisay, Bayeh Abera
Categories: Research, Pharyngitis, Drug resistance, Bacterial, Child, Ethiopia
Source: BMC Infectious Diseases
Authors: Kefiyalew Mihrete, Tewachew Awoke, Addisu Melake, Tadese Sisay, Bayeh Abera
Bacterial pharyngitis is a common childhood infection involving inflammation of the pharynx and tonsils. Compared to viral causes, it often presents more severely and can result in complications if untreated. However, data on its bacterial etiology, resistance patterns, and associated risk factors are limited in developing countries, including Ethiopia.
To assess the prevalence, bacterial causes, antimicrobial susceptibility patterns, and risk factors of pharyngitis among children at comprehensive specialized hospitals, Northwest Ethiopia.
A hospital-based cross-sectional study was conducted from June 1 to August 30, 2024, among 254 children aged ≤ 14 years. Throat swabs were collected and cultured following standard microbiological techniques. Bacterial identification was performed through colony morphology, Gram staining, and biochemical tests. Antimicrobial susceptibility was tested using the Kirby-Bauer disk diffusion method. Data were analyzed using SPSS version 27, and logistic regression identified significant risk factors (p ≤ 0.05).
The prevalence of culture-confirmed bacterial pharyngitis was 28.3% (95% CI: 22.5–33.9%). A total of 80 bacterial isolates were identified, predominantly Streptococcus pyogenes (35%), Staphylococcus aureus (32.5%), and Streptococcus pneumoniae (28.8%). High resistance was S. pyogenes to ceftriaxone (64.3%) and chloramphenicol (53.6%); S. pneumoniae to penicillin (82.6%); and S. aureus to penicillin (80.8%) and tetracycline (57.7%). Overall, 41.3% of isolates exhibited multidrug resistance. Significant factors associated with bacterial pharyngitis included prior history of pharyngitis (AOR = 8.86), tonsillectomy (AOR = 5.65), contact with coughing individuals (AOR = 3.42), and weight loss (AOR = 2.58).
Bacterial pharyngitis is prevalent among children in the study area, with a high burden of multidrug-resistant organisms. Routine use of culture and antibiotic susceptibility testing is essential to guide effective treatment and reduce resistance.
Not applicable.
The online version contains supplementary material available at 10.1186/s12879-025-12427-8.
Pharyngitis, an inflammation of the pharyngeal mucosa and tonsillar structures, is among the most common upper respiratory tract infections, particularly affecting children. Because of its close proximity to the salivary glands, oral cavity, and external environment, the human pharynx—a mucus-rich, aerated anatomical region—is constantly exposed to a variety of microbial agents [1, 2]. A common cause of pediatric morbidity, bacterial pharyngitis is mostly caused by Streptococcus pyogenes (Group A Streptococcus, or GAS) and is frequently transmitted by direct contact with respiratory secretions or infected surfaces [3]. The illness burden is also influenced by other bacterial infections, including Moraxella catarrhalis, Haemophilus influenzae, Staphylococcus aureus, and Streptococcus pneumoniae [4].
Because of its high frequency and potential for major problems, particularly if left untreated, pharyngitis in children is a specific concern. These consequences include glomerulonephritis, rheumatic heart disease, otitis media, peritonsillar abscess, and even potentially fatal disorders including airway obstruction and septicemia [5, 6]. Young age, overcrowding, seasonal fluctuations, exposure to environmental factors (such as smoke and dust), and a history of recurrent infections or contact with sick people are all factors that increase the risk of contracting the disease [7, 8].
The rising incidence of antimicrobial resistance (AMR) among the bacterial pathogens that cause pharyngitis is a cause for increasing concern. Irrational antibiotic usage and self-medication have been the driving forces for resistance mechanisms, such as the creation of beta-lactamases, genetic mutation, and biofilm formation [9, 10]. The AMR epidemic has been made worse in resource-constrained environments such as Ethiopia by inadequate diagnostic infrastructure, restricted access to microbiological testing, and inappropriate use of antibiotics [11, 12].
In the study area, limited local epidemiological data exist [13] on the bacterial profile, antibiotic susceptibility patterns, and associated risk factors among pediatric populations, despite the clinical and public health importance of bacterial pharyngitis. Current and thorough information on the prevalence and microbiological characteristics of bacterial pharyngitis in children is lacking in northwest Ethiopia [14]. In order to ascertain the frequency of bacterial pharyngitis, pinpoint the causing organisms, ascertain their patterns of antibiotic susceptibility, and investigate the risk factors linked to it, this study was conducted among pediatric patients who were seen at comprehensive specialized hospitals, Northwest Ethiopia.
A hospital-based cross-sectional study was conducted from June 1 to August 30, 2024, at two specialized hospitals located in Northwest Ethiopia: Felege Hiwot Specialized Hospital (FHSH) and Tibebe Ghion Specialized Teaching Hospital (TGSH). These tertiary-level institutions provide comprehensive inpatient and outpatient services to a wide catchment area across the Amhara Regional State and surrounding regions.
Both FHSH and TGSH function as referral centers and are equipped with advanced diagnostic and therapeutic facilities. They serve as medical teaching and research hospitals affiliated with regional health science institutions. The hospitals include well-established pediatric departments, alongside other specialized units, and play a critical role in delivering healthcare services and clinical training in Northwest Ethiopia.
The source population included all pediatric patients visiting FHSH and TGSH during the study period. The study population consisted of children under 14 years old presenting with signs and symptoms of pharyngitis.
Children ≤ 14 years with clinical features of pharyngitis.Patients or guardians willing to provide informed consent.
Children who had received antibiotics within the past two weeks.Children or guardians who declined participation.
Dependent Variables Presence of bacterial pharyngitisAntimicrobial susceptibility patterns
Independent variables Socio-demographic: Age, sex, parental education, residenceClinical: History of pharyngitis, contact with coughing patientEnvironmental: Exposure to wood smoke, overcrowding, school attendanceClinical Signs: Tonsillar swelling, exudate, fever > 38 °C, difficulty swallowing, lymph node enlargement, tonsillectomy status, vaccination history
Pediatric children: For this study, children aged 0–14 years.Bacterial pharyngitis: Pharyngitis cases confirmed through positive bacterial culture.Immunization defined as fully immunized or not fully immunized according to the Ethiopian National Expanded Program on Immunization (EPI) schedule for the child’s age. Immunization status was verified using vaccination cards when available or caregiver report otherwise.Clinical Variables: History of Recorded as a binary variable (Yes = previous episodes reported; No = no previous episodes).Contact with a coughing Recorded as binary (Yes = child had close contact with someone with cough in the past 2 weeks; No = no contact).Environmental Variables: Exposure to wood Assessed by caregiver report of whether the child is regularly exposed to indoor cooking smoke (Yes/No).Overcrowding: Measured as the number of persons per room in the household, categorized for analysis as ≤ 3 persons/room or > 3 persons/room.School Recorded as binary (Yes = attending school; No = not attending school).
The sample size was calculated using a single population proportion formula,
95% confidence level (Z = 1.96)5% margin of error (d)Prevalence (p) = 21.3% (based on a prior study in Harar, Ethiopia)
Single population proportion formula.
The sample size
\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \mathrm{n}=\frac{\mathrm{z}\left(\upalpha/2\right)^{2}:\mathrm{p}\left(\mathrm{1-p}\right)}{\mathrm{d}^{2}}
Z (α/2)^2^ = at 95% confidence interval = 1.96 P = Proportion of occurrence of the event to be studied 16.1% (0.213) d = Margin of error at (5%) \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \begin{aligned}&\mathrm{n}=\frac{{1.96^{2}}^{*}0.213^{*}(\mathrm{1-0.213})}{(0.05)^{2}}\cr&\:\:=\frac{(3.8416)^{*}0.213^{*}(0.787)}{0.0025}\cr&\:\:=258\end{aligned} $$\end{document} There were non-responsive patients; the final sample size was 254. ### Sampling technique A convenience sampling technique was employed to recruit eligible participants from the pediatric outpatient and emergency departments. ### Data collection A pre-tested, structured questionnaire was administered by trained clinical officers to collect demographic, environmental, and clinical information. The questionnaire was adapted from validated tools and pre-tested at Debre Tabor Comprehensive Specialized Hospital. The prepared questionnaires are attached in the supplementary file. ### Sample collection and transportation Throat swabs were collected aseptically using sterile cotton swabs by rotating across both tonsils and posterior pharyngeal wall. The swabs were placed in Amies transport medium and transported to the Bahir Dar University Microbiology Laboratory for processing within two hours of collection. ### Laboratory investigation #### Culture and identification Swabs were inoculated on 5% sheep blood agar (HiMedia, India; Cat. No. M1301-100G(100g), chocolate agar (with 5 µg/mL gentamicin), and MacConkey agar (HiMedia, India; Cat. No. M081B‑100 g.Plates were incubated at 37 °C for 18–24 h in 5% CO₂ candle jars.Colonies were identified based Hemolysis β-hemolysis (*S. pyogenes*, *S. aureus*), α-hemolysis (*S. pneumoniae*), non-hemolytic (M. catarrhalis).Biochemical catalase, coagulase, bacitracin, optochin, bile solubility, oxidase, indole, citrate, and TSI.Gram staining was performed for bacterial characterization. #### Quality control strains *S. aureus* ATCC 25,923*S. pneumoniae* ATCC 49,619*H. influenzae* ATCC 49,241 ### Antimicrobial susceptibility testing Antibiotic susceptibility was assessed using the Kirby-Bauer disk diffusion method on Mueller-Hinton Agar (MHA) and MHA supplemented with blood for fastidious organisms. Suspensions were adjusted to 0.5 McFarland standard before inoculation. The zone of inhibition was measured and interpreted according to CLSI 2023 guidelines. ### Data quality control 5% of questionnaires were pre-tested for clarity and consistency.Standard operating procedures (SOPs) were strictly followed.Culture media were tested for sterility and performance.Laboratory processes were validated using reference strains.Daily temperature logs and equipment calibration were maintained. ### Data analysis Data were entered into Epi Data version 4.6, cleaned, and exported to SPSS version 27 for analysis. Descriptive statistics were computed, and associations were examined using Chi-square tests and binary logistic regression, with a p-value ≤ 0.05 considered statistically significant. Prior to the multivariable analysis, multicollinearity among independent variables was assessed using Variance Inflation Factor (VIF) and tolerance statistics. Although values of VIF ≥ 10 or tolerance ≤ 0.1 are typically indicative of multicollinearity, more conservative thresholds (VIF < 2.5 and tolerance > 0.4) were applied due to the conceptual overlap between certain variables (e.g., school attendance and history of contact with symptomatic individuals). All predictors met these criteria, confirming the absence of significant multicollinearity, and were therefore retained in the final model. ### Ethical considerations Ethical clearance was granted by the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, Bahir Dar University (Ref: CMHS 1037/2024). Support letters were provided to the study hospitals. Written informed consent was obtained from parents or legal guardians. Data confidentiality and participant anonymity were strictly maintained throughout the study in accordance with the Declaration of Helsinki. ## Results ### Socio-demographic features and prevalence of bacterial pharyngitis In this study, of the total study participants, 124 (48.8%) were males and 111 (43.7%) were rural living. The participants’ age range was up to 14 years; of which 98 (38.6%) were ≤ 5 years and 83 (32.7%) were 6–10 years (Table 1). The overall prevalence of culture-confirmed bacterial pharyngitis was 28.3% (95% CI: 22.5–33.9%). Table 1Socio-demographic characteristics of pediatric participants and prevalence of culture-confirmed bacterial pharyngitis in specialized hospitals, Northwest Ethiopia, 2024VariablesBacterial culture results*P* value (χ2)FrequencyPositive (%)Negative (%)Children age (Years)≤ 59826 (26.5%)72 (73.5)0.45 (χ2 = 0.55)6–108326 (31.3%)57 (68.7%)11–147320 (27.4%)53 (72.6%)SexMale12444 (35.5%)80 (64.5%)**0.014** (χ2 = 6.07)Female13028 (21.5%)102 (78.5%)ResidenceRural11139 (35.1%)72 (64.9%)0.035 (χ2 = 4.47)Urban14333 (23.1%)110 (76.9%) ### Clinical profiles of children with bacterial pharyngitis Children with bacterial pharyngitis presented with a range of clinical symptoms, including high body temperature (≥ 38) in 175 (68.9%), weight loss in 136 (53.5%), and swollen lymph nodes in 156 (61.4%) (Table 2). Table 2Clinical characteristics of pediatric patients with culture-confirmed bacterial pharyngitis in specialized hospitals, Northwest Ethiopia, 2024VariablesBacterial culture results*P* value and (χ2)Frequency (%)Positive (%)Negative (%)Weight lossYes136 (53.5)54 (39.)82 (60.3)**0.0001** (χ2 = 18.6)No118 (46.5)18 (15.)100 (84.7)Tonsil structural ChangesYes131 (51.6)75 (57.3)56 (42.7)**0.0001** (χ^2^ = 54.01)No123 (48.4)16 (13)107 (87)Type of PharyngitisAcute95 (37.4)17 (17.9)78 (82.1)**0.0001** (χ^2^ = 14.8)Chronic80 (31.5)35 (43.8)45 (56.2)Recurrent79 (31.1)20 (25.3)59 (74.7)Body Temperature(fever)3779 (31.1)17 (21.5)62 (78.5)0.105 (χ^2^ = 2.6)≥ 38175 (68.9)55 (31.4)120 (68.6)White pharyngeal ExudateYes88 (34.6)31 (35.2)57 (64.8)0.076 (χ2 = 3.2)No166 (65.4)41 (24.7)125 (75.3)Swollen lymph NodesYes156 (61.4)50 (32.1)106 (67.9)0.098 (χ2 = 2.7)No98 (38.6)22 (22.4)76 (77.6)Difficult to swallow foodYes146 (57.5)51 (34.9)95 (65.1)0.007 (χ2 = 7.3)No108 (42.5)21 (19.4)87 (80.6) ### Factors contributing to bacterial pharyngitis in pediatric patients Several factors were associated with culture-confirmed bacterial pharyngitis, including history of contact with symptomatic individuals, prior pharyngitis, tonsillectomy, immunization status, school attendance, and tonsillar structural changes (Table 3). Table 3Factors associated with bacterial pharyngitis and prevalence of culture-confirmed cases among pediatric patients in specialized hospitals, Northwest Ethiopia, 2024VariablesBacterial culture results*P* value (χ2)Frequency (%)Positive F (%)Negative F (%)History of contact with cough patientsYes124 (48.9)54 (43.5)70 (56.5)**0.0001** (χ2 = 27.6)No130 (51.1)18 (13.8)112 (86.2)History of PharyngitisYes131 (51.6)56 (42.7)75 (57.3)0.001(x2 = 27.5)No123 (48.4)16 (13)107 (87)TonsillectomyYes129 (50.8)53 (41.1)19 (58.9)**0.0001** (χ2 = 27.6)No125 (49.2)76 (15.2)106 (84.8)Immunization statusYes129 (50.8)18 (16.4)107 (83.6)**0.0001** (χ2 = 23.5)No125 (48.2)54 (40.5)75 (59.5)Attending schoolYes120 (47.2)50 (41.6)70 (58.3)0.0001 (χ2 = 19.8)No134 (52.8)22 (16.4)112 (83.6)Live overcrowded set upYes122 (48)47 (38.5)75 (61.5)0.0005 (χ2 = 11.9)No132 (52)25 (18.9)107 (81.1)Exposed dung/wood biofuelYes123 (48.4)44 (35.8)79 (64.2)0.011 (χ2 = 6.5)No131 (51.6)28 (21.4)103 (78.6) ### Distribution of bacteria isolates *S. pyogenes* 28 (35%) was the most frequently identified bacteria, followed by *S. aureus* 26 (32.5%), and *S. pneumoniae* 23 (28.8%) were found on throat swab samples. Mixed isolates were 5 (6.3%) *S. pyogenes and S. aureus* and 3 (3.8%) *S. pneumoniae and K. pneumoniae* (Fig. 1). Fig. 1Distribution of bacterial isolates from pediatric patients with pharyngitis in specialized hospitals, Northwest Ethiopia, 2024 ### Bacterial isolates and their antimicrobial resistance The most frequently identified bacterial isolates were *S. pyogenes* (35%), *S. aureus* (32.5%), and *S. pneumoniae* (28.8%), with a small proportion of mixed infections (9%). Resistance was observed against commonly used antibiotics, including chloramphenicol (53.8%), gentamicin (52.5%), tetracycline (50%), and ceftriaxone (46.3%) (Table 4). Table 4Antimicrobial susceptibility patterns of bacterial isolates from pediatric patients with bacterial pharyngitis in specialized hospitals, Northwest Ethiopia, 2024Antibiotics testPercentage of bacterial isolates susceptible or resistant to, *n* (%)AUGAMXETECCIPGMCRO *P* Total *N* (%)*S. pyogenes* (28)S = N%22 (78.6)20(71.4)16(57.1)15 (54)13(46.4)16 (57.1)14 (50)10(35.7)28(100%)R = N%6 (21.4)8 (28.6)12(42.9)13 (46)15(53.6)12 (42.9)14 (50)18(64.3)098 (39.7)*S. aureus* (26)S = N%19 (73.2)18(69.2)16(61.5)11(42.3)10(38.5)11 (42.3)12(46.2)15(57.7)5 (19.2)R = N%7 (26.9)8 (30.8)10(38.5)15(57.7)16(61.5)15 (57.7)14(53.8)11(42.3)21(80.8)117(50)*S. pneumoniae* (23)S = N%16 (69.6)14(60.9)15(65.2)13(56.5)13(56.5)20 (87)11(47.8)16(69.6)4 (17.4)R = N%7 (30.4)9 (39.1)8 (34.8)10(43.5)10 (43.53 (13)12(52.2)7 (30.4)19 (82.6)85(41,1)*K. Pneumoniae* (3)S = N%1 (33.3)01 (33.3)1 (33.3)1 (33.3)3 (100)1 (33.3)2 (66.7)0R = N%2 (66.7)3 (100)2 (66.7)2 (66.7)2 (66.7)02 (66.7)1 (33.3)3 (100)17(62.9)Total = 80R = N%22/80 (27.5)28 (35)32 (40)40(50)43(53.8)30 (37.5)42(52.5)37(46.3)43 (53. 8)319(39.8)CRO = Ceftriaxone AUG = Augmentin, AMX = Amoxicillin, E = Erythromycin, TE = Tetracycline, C = Chloramphenicol, CIP = Ciprofloxacin, GM = Gentamicin, p = penicillin, S = susceptible, R = resistance ### Profiles of MDR bacterial isolates The overall multidrug-resistance (MDR) rate of bacterial species was 33 (41.3%). The overall MDR of each bacterium, *S. pyogenes*, *S. aureus*, and *S. pneumoniae* was 9 (32.1%), 12 (46.2%), and 10 (43.5%) respectively (Table 5). Table 5Profiles of multidrug-resistant (MDR) bacterial isolates from pediatric patients with bacterial pharyngitis in specialized hospitals, Northwest Ethiopia, 2024AntibioticsS. pyogenes (28)S.aureus (26)S. pneumoniae (23)K. pneumoniae (3)Total (80)R1 N (%)15 (53.6%)8 (30.8%)5 (21.7%)028 (35%)R2 N (%)3 (10.7%)6 (23.1%)8 (34.7%)1 (33.3%)18 (22.5%)R3 N (%)3 (10.7%)2 (7.7%)5 (21.7%)010 (12.5%)R4 N (%)4 (14.2%)5 (19.2%)4 (17.4%)1 (33.3%)14 (17.5%)R5 N %2 (7%)3 (11.5%)1 (4.3%)06 (7.5%)R6 N %0 (0.0%)2 (7.7%)01 (33.3%)3 (3.8%)Over all MDR N (%)9 (32.1%)12 (46.2%)10 (43.5%)2 (66.7%)33 (41.3%) ### Factors associated with bacterial pharyngitis Bacterial pharyngitis was significantly associated with weight loss (AOR = 2.58, 95% CI: 1.1–6.05), chronicity (AOR = 2.93, 95% CI: 1.08–7.94), history of contact with patients (AOR = 3.42, 95% CI: 1.47–7.95), prior history of pharyngitis (AOR = 8.86, 95% CI: 3.37–23.29), tonsillectomy (AOR = 5.65, 95% CI: 2.37–13.46), immunization status (AOR = 4.22, 95% CI: 1.74–10.24), school attendance (AOR = 3.44, 95% CI: 1.44–8.2), and tonsillar structural changes (AOR = 2.53, 95% CI: 1.03–6.22). Children with weight loss were 2.5 times more likely to be culture-positive for bacterial pharyngitis compared to those without. Similarly, school attendees were three times more likely to test positive than non-attendees. A history of contact with symptomatic individuals increased the odds 3.4-fold, while a prior history of pharyngitis raised it nearly nine fold. Children with a history of tonsillectomy, unimmunized status, or tonsillar structural changes were 5.7, 4.2, and 2.5 times more likely, respectively, to have culture-confirmed bacterial pharyngitis (Table 6). Table 6Bivariate and multivariable analysis of factors associated with bacterial pharyngitis among pediatric patients in specialized hospitals, Northwest Ethiopia, 2024VariablesCOR (95%CI)*P*-valueAOR (95%CI)*P*-valueSexMale2 (1.15–3.49)0.0141.49 (0.65–3.38)0.346Female11ResidenceRural1.8 (1.04–3.13)0.0351.36 (0.60–3.08)0.46Urban11Weight lossYes3.7 (1.99–6.72)< 0.0012.58 (1.1–6.05)0.030No11Tonsil structural ChangeYes5 (2.66–9.37)< 0.0012.53 (1.03–6.22)0.043No11Type of PharyngitisAcute11Chronic3.6 (1.8–7.1)< 0.0012.93 (1.08–7.94)0.034Recurrent1.6 (0.75–3.22)0.2351.26 (0.43–3.69)0.678Body T°37 °C11≥ 38 °C1.7 (0.89–3.1)0.1071.43 (0.55–3.73)0.468White pharyngeal exudateYes1.7 (0.95–2.91)0.0781.76 (0.76–4.08)0.188No11Swollen lymph nodesYes1.6 (0.91–2.92)0.1001.05 (0.45–2.44)0.917No11Difficult to swallow foodYes2.2 (1.24–3.99)0.0071.64 (0.70–3.85)0.253No11History of Contact with patientsYes4.8 (2.61–8.85)< 0.0013.42 (1.47–7.95)0.004No11History pharyngitisYes5 (2.66–9.37)< 0.0018.86 (3.37–23.29)0.001No1TonsillectomyYes3.9 (2.13–7.09)< 0.0015.65 (2.37–13.46)0.001No11Immunization statusYes11No4.3 (2.34-8)< 0.0014.22 (1.74–10.24)0.001Attending schoolYes3.6 (2-6.5)< 0.0013.44 (1.44–8.2)0.005No11Live overcrowded setupYes2.7 (1.52–4.73)0.0011.82 (0.79–4.19)0.161No11Exposed wood biofuelYes2 (1.17–3.58)0.0121.37 (0.59–3.17)0.462No11 ## Discussion In this study, the prevalence of culture-confirmed bacterial pharyngitis among pediatric patients at specialized hospitals was 28.3% (95% CI: 22.5–33.9%). This finding is comparable to a study from Norway (27%) [15], but higher than studies from Brazil (20.6%) [16, 17] and Jimma, Ethiopia (8.8%) [18]. Conversely, it is lower than reports from Malaysia (43.4%) [19], Nigeria (83.3%) [4], Pakistan (78.1%) [20], Iraq (93.1%) [21], Somaliland (32.2%) [22], and Ethiopia (75.1%) [1]. The observed differences may be due to variations in sample size, geographical and environmental factors, immunization coverage, diagnostic methods, the use of self-medication, and the emergence of antimicrobial resistance. Male children had a higher proportion of culture-confirmed bacterial pharyngitis, consistent with findings from Riyadh [23], Cairo [24], Iraq [25], Nigeria [4], and Ethiopia [26]. This is clinically meaningful, suggesting that targeted health education and preventive interventions may be needed for boys in school and community settings. Children from rural areas showed a higher prevalence of bacterial pharyngitis than urban dwellers, aligning with findings from Hawassa [26] and Bahir Dar, Ethiopia [27]. This association is significant and highlights the need to improve healthcare access, vaccination coverage, and hygiene practices in rural communities. Chronic pharyngitis was also associated with a higher bacterial isolation rate (43.8%), although slightly lower than the 57.7% reported in Somaliland [22]. The discrepancy may be explained by differences in chronicity definitions, local bacterial strains, self-medication practices, and immunization status. *Streptococcus pyogenes* was the most frequently isolated pathogen (35%), lower than Tanzania (40%) [28], Sudan (41.4%) [29], Somaliland (55%) [22], and Ethiopia (42.5%) [30], but higher than in Nigeria (11.6%) [31] and Kenya (13.7%) [32]. Such variations may reflect differences in strain diversity, population density, antibiotic exposure, and diagnostic methods. *S. pyogenes* resistance to chloramphenicol (53.6%), gentamicin (50%), and ceftriaxone (64.3%) is clinically significant, indicating that empirical treatment regimens may need to be updated locally. *Staphylococcus aureus* accounted for 32.5% of isolates, similar to findings from Somaliland (29%) [22] and Bahir Dar (29%) [27], but higher than in Iraq (19.5%) [25] and Kenya (16.6%) [32], and lower than Brazil (63%) [33]. Differences may be due to factors such as biofilm formation, antibiotic resistance, and tonsillar infections like tonsilloliths. *Streptococcus pneumoniae* was isolated in 28.8% of cases, higher than reported in Nigeria (8.5%) [34], Kenya (10.3%) [32], and Somaliland (7%) [22]. This could be attributed to low immunization coverage, regional antimicrobial resistance patterns, or diagnostic variation. *Klebsiella pneumoniae* was identified in 3.8% of cases, consistent with findings from Somaliland (4%) [22] and Addis Ababa (4%) [35], but lower than Libya (43.3%) [16] and Kenya (20.6%) [32]. Regional differences in pathogen prevalence, immunity levels, and healthcare access could explain these disparities. Importantly, recent molecular data from Iran show that K. pneumoniae frequently carries ESBL and carbapenemase genes, including blaSHV, blaTEM, blaCTX-M, and blaOXA-48, and demonstrates substantial MDR patterns [36]. Such emerging regional resistance trends highlight the need for surveillance in Ethiopia as well. Regarding antimicrobial resistance, *S. pyogenes* showed high resistance to chloramphenicol (53.6%), gentamicin (50%), and ceftriaxone (64.3%). These rates are markedly higher than those reported in Gondar (5%, 9%, and 13%, respectively) [37]. Resistance mechanisms such as aminoglycoside-modifying enzymes and mutations in quinolone-resistance determining regions may be involved. *S. aureus* demonstrated high resistance to penicillin (80.8%), tetracycline (57.7%), gentamicin (53.8%), and chloramphenicol (61.5%), comparable to findings from Bahir Dar (84.1%) [27], but higher than in Gondar (65%) [37] and Somaliland (38%) [22]. These patterns likely reflect overuse of antibiotics, poor prescribing practices, and resistance gene acquisition. *S. pneumoniae* showed resistance to penicillin (82.6%) and gentamicin (52.2%), rates exceeding those from Germany (43%) [38], the USA (38.9%) [39], and China (56% and 21%, respectively) [40]. These findings underscore the consequences of limited vaccination, over-the-counter antibiotic access, and diagnostic gaps. Antimicrobial resistance patterns showed alarmingly high resistance rates, particularly to penicillin, which reached 80.8% across isolates. *S. pyogenes* demonstrated high resistance to chloramphenicol (53.6%), gentamicin (50%), and ceftriaxone (64.3%), while *S. aureus* showed resistance to penicillin (80.8%), tetracycline (57.7%), gentamicin (53.8%), and chloramphenicol (61.5%). These findings highlight the increasing burden of multidrug-resistant organisms (41.3% MDR overall), likely driven by antibiotic overuse, self-medication, and limited diagnostic testing. Several factors were significantly associated with culture-confirmed bacterial incomplete or no immunization, prior history of pharyngitis, contact with coughing individuals, and history of tonsillectomy, chronic pharyngitis, school attendance, and visible tonsillar structural changes. These associations are consistent with findings from studies in India, Riyadh, Nigeria, Somaliland, and various Ethiopian regions [7, 22, 26, 41, 42]. These associations are clinically meaningful because they identify high-risk groups that can benefit from targeted interventions such as vaccination campaigns, health education, and early treatment programs. This study provides valuable insights into the bacterial etiologies and antimicrobial resistance patterns of pediatric pharyngitis; however, it has limitations. These include the use of convenience sampling, the absence of molecular confirmation of bacterial isolates, and the lack of investigation for viral and fungal causes of pharyngitis. ## Conclusion The study identified *S. pyogenes*, *S. aureus*, and *S. pneumoniae* as the predominant bacterial pathogens in pediatric pharyngitis, with a notable proportion exhibiting resistance to commonly used antibiotics, including multidrug-resistant patterns. Factors such as incomplete vaccination, prior history of pharyngitis, contact with symptomatic individuals, tonsillar structural changes, school attendance, and prior tonsillectomy were significantly associated with bacterial pharyngitis. These findings underscore the importance of local antimicrobial surveillance, cautious antibiotic use, and preventive strategies. Further research with larger, representative samples and molecular diagnostic approaches is recommended to strengthen these observations. ## Supplementary Information Below is the link to the electronic supplementary material. Supplementary Material 1