3. EPIDEMIOLOGY
Outbreaks first described in 16th century
Bordetella pertussis isolated in 1906
Estimated >500,000 deaths annually worldwide
4. EPIDEMIOLOGY
Despite widespread vaccination, the incidence of pertussis has been rising since
the 1990s
particularly in infants younger than one year, who are at the greatest risk of
morbidity and mortality
Atypical/mild and asymptomatic infections are increasingly recognized in older
children and adults but may be underreported
6. Mode of Transmission
Highly communicable acute respiratory infection caused by B. pertussis
Person-to-person transmission through aerosolised respiratory droplets
surviving only a few hours in respiratory secretions outside of the human body
As many as 80% of susceptible household contacts become infected after
exposure
Humans are the sole reservoir
7. MICROBIOLOGY
Other Bordetella species, including:
B. parapertussis,
B. bronchiseptica,
B. holmesii,
may cause a clinical syndrome similar to whooping cough but are generally less
severe.
8. Clinical Manifestations of Pertussis
Incubation period 3-12 days (up to 21 days)
Insidious onset, similar to minor upper respiratory infection with nonspecific cough
Fever usually minimal throughout course
Apnea & Cyanosis in infant
14. Hospitalization
Indications – Indications for hospitalization in infants and children with pertussis
infection or suspected pertussis infection includ:
Respiratory distress, including tachypnea, retractions, nasal flaring, grunting,
and the use of accessory muscles
Evidence of pneumonia
Inability to feed
Cyanosis or apnea, with or without coughing
Seizures
Age <4 months
15. Isolation
Standard precautions, as well as droplet precautions (mask within 3 feet), are
recommended for children with pertussis who are admitted to the hospital
These precautions should be in effect until five days of effective therapy have
been administered
or three weeks after the onset of symptoms in untreated patients
16. Discharge criteria
Minimum criteria for discharge include:
Ability to tolerate coughing episodes without becoming hypoxic and/or
bradycardic; most infants who are admitted to the hospital with pertussis
continue to have coughing paroxysms after discharge
Ability to eat enough to gain weight
Reliable caretakers who are comfortable caring for the child at home
Assurance of close outpatient follow-up
17. Fluids and nutrition
Infants and children with frequent paroxysms of cough may have increased fluid
and energy needs, which can be difficult to meet if the infant is coughing or
vomiting.
NGT
18. Antimicrobial therapy
Indications :
cultures or positive PCR within three weeks of cough onset (individuals >1
year) or six weeks of cough onset (individuals <1 year)
infants and children with a clinical diagnosis of pertussis (with or without
laboratory confirmation) who have had symptoms <21 days
have had >21 days of symptoms, particularly those who are likely to be in
contact with high-risk individuals
19. Early treatment (ie, within seven days of symptom onset) may decrease the severity
of symptoms
21. Age group Azithromycin Erythromycin Clarithromycin
<1 month
10 mg/kg per day
in a single dose
for 5 days
(only limited safety data
available)
Not preferred;
associated with infantile
hypertrophic pyloric stenosis;
use if azithromycin is
unavailable; 40 mg/kg per day
in four divided doses for 14
days
Not recommended
(safety data
unavailable)
1 to 5
months
10 mg/kg per day in a
single dose for 5 days
40 mg/kg per day in four
divided doses for 14 days
15 mg/kg per day
in two divided doses
for 7 days
Infants
(aged ≥6
months) and
children
10 mg/kg
in a single dose on day 1
(maximum: 500 mg) then
5 mg/kg per day
(maximum: 250 mg) on
days 2 through 5¶
40 mg/kg per day in four
divided doses for 7 to 14 days
(maximum: 2 g per day)
15 mg/kg per day
in two divided doses
for 7 days (maximum:
1 g per day)
Adults
500 mg in a single dose
on day 1 then
250 mg per day on days
2 through 5¶
2 g (base) per day in four
divided doses for 7 to 14 days
1 g per day in two
divided doses for 7
days
22. Post exposure prophylaxis
Antibiotic prophylaxis has traditionally been used to prevent transmission to
personal contacts of patients with pertussis
The CDC recommends that prophylaxis given within the first 21 days of
illness be considered for all close contacts, including family members,
caretakers, and health care professionals
a placebo-controlled trial of erythromycin prophylaxis, investigators found that
erythromycin did not significantly reduce the frequency of either paroxysmal
or whooping-type coughs in contacts, nor did it significantly reduce the
number of contacts who developed a positive culture.
Azithromycin is the preferred agent for prophylaxis
23. Complications
hypoxia, apnea, pneumonia, seizures, encephalopathy, and malnutrition
The most frequent complication is pneumonia
Atelectasis may develop secondary to mucous plugs.
The force of the paroxysm may rupture alveoli and produce
pneumomediastinum pneumothorax, or interstitial or subcutaneous
emphysema
epistaxis; hernias; and retinal and subconjunctival hemorrhages
24.
25. Pertussis Cycle
Pertussis primary vaccination in
the first year of life
Non-vaccinated or partially
vaccinated infants: risk of
complications
Adults and adolescents serve
as reservoirs of pertussis infection.
New parents present a heightened risk
of transmission
Pertussis booster
vaccination in the second
year of life
No Pertussis booster
vaccination: protection wears off
with time
28. Prevention
Close contacts – Close contacts are defined by:
Living in the same household
Face-to-face exposure within 3 feet of a symptomatic patient
Direct contact with respiratory, oral, or nasal secretions from a symptomatic
patient
Sharing the same confined space in close proximity with a symptomatic
patient for ≥1 hour
29.
30. References
up-to-date
Hoppe JE. Comparison of erythromycin estolate and erythromycin ethylsuccinate for treatment of
pertussis. The Erythromycin Study Group. Pediatr Infect Dis J 1992; 11:189.
Bass JW, Klenk EL, Kotheimer JB, et al. Antimicrobial treatment of pertussis. J Pediatr 1969;
75:768.
Steketee RW, Wassilak SG, Adkins WN Jr, et al. Evidence for a high attack rate and efficacy of
erythromycin prophylaxis in a pertussis outbreak in a facility for the developmentally disabled. J
Infect Dis 1988; 157:434.
Bergquist SO, Bernander S, Dahnsjö H, Sundelöf B. Erythromycin in the treatment of pertussis: a
study of bacteriologic and clinical effects. Pediatr Infect Dis J 1987; 6:458.
Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis).
Cochrane Database Syst Rev 2007; :CD004404.
Adapted Wendelboe AM et al., Pediatr Infect Dis J. 2007;26(4):293-299; Wirsing von Konig CH. et
al., The Lancet Infectious Disease 2002; 2 (12): 744—50
