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Staying Ahead of Pertussis

Clinician Reviews. 2014 November;24(11):658-659,666-669

References

1. Orenstein WA. Pertussis in adults: epidemiology, signs, symptoms, and implications for vaccination. Clin Infect Dis. 1999;28 suppl 2:S147-S150.

2. Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999. JAMA. 2003;290:2968-2975.

3. Vitek CR, Pascual FB, Baughman AL, et al. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. 2003;22:628-634.

4. Centers for Disease Control and Prevention. Pertussis outbreak trends. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/pertussis/outbreaks/trends.html. Accessed October 10, 2014.

5. Shapiro ED. Acellular vaccines and resurgence of pertussis. JAMA. 2012;308:2149-2150.

6. Centers for Disease Control and Prevention. Pertussis. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book. 2012. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html. Accessed October 10, 2014.

7. Centers for Disease Control and Prevention. Pertussis: Summary of vaccine recommendations. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/vaccines/vpd-vac/pertussis/recs-summary.htm. Accessed October 10, 2014.

8. Lee GM, Murphy TV, Lett S, et al. Cost effectiveness of pertussis vaccination in adults. Am J Prev Med. 2007;32:186-193.

9. Pertussis vaccines: WHO position paper. Wkly Epidemiol Rec. 2010;85:385-400.

10. Kretsinger K, Broder KR, Cortese MM, et al; Centers for Disease Control and Prevention; Advisory Committee on Immunization Practices; Healthcare Infection Control Practices Advisory Committee. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among healthcare personnel. MMWR Recomm Rep. 2006;55(RR-17):1-37.

11. English P. Pertussis vaccination in pregnant women will protect neonates. Practitioner. 2012;256:5.

12. Winter K, Harriman K, Zipprich J, et al. California pertussis epidemic, 2010. J Pediatr. 2012;161:1091-1096.

13. Centers for Disease Control and Prevention (CDC). Pertussis epidemic—Washington, 2012. MMWR Morb Mortal Wkly Rep. 2012;61:517-522.

14. Klein NP, Bartlett J, Rowhani-Rahbar A, et al. Waning protection after fifth dose of acellular pertussis vaccine in children. N Engl J Med. 2012;367:1012-1019.

15. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2012;61:468-470.

16. Cherry JD, Tan T, Wirsing von Konig C, et al. Clinical definitions of pertussis: Summary of a global pertussis initiative roundtable meeting, February 2011. Clin Infect Dis. 2012;54:1756-1764.

17. Zouari A, Smaoui H, Kechrid A. The diagnosis of pertussis: which method to choose?. Crit Rev Microbiol. 2012;38:111-121.

18. Loeffelholz MJ, Thompson CJ, Long KS, et al. Comparison of PCR, culture, and direct fluorescent-antibody testing for detection of Bordetella pertussis. J Clin Microbiol. 1999;37:2872-2876.

19. Tozzi A, Celentano L, Ciofi degli Atti ML, et al. Diagnosis and management of pertussis. CMAJ. 2005;172:509-515.

20.  von König CH, Halperin S, Riffelmann M, et al. Pertussis of adults and infants. Lancet Infect Dis. 2002;2:744-750.

21. Cattaneo LA, Edwards KM. Bordetella pertussis (whooping cough). Semin Pediatr Infect Dis. 1995;6:107-117.

22. Hoppe JE, Eichhorn A. Activity of new macrolides against Bordetella pertussis and Bordetella parapertussis. Eur J Clin Microbiol Infect Dis. 1989;8:653-654.

23. Bass JW. Erythromycin for treatment and prevention of pertussis. Pediatr Infect Dis. 1986;5:154-157.

24. Health Protection Surveillance Centre. Guidelines for the Public Health Management of Pertussis: Public Health Medicine Communicable Disease Group HSE—October 2013. Health Protection Surveillance Centre Web site. Available at: http://www.hpsc.ie/A-Z/VaccinePreventable/PertussisWhoopingCough/InformationforHealthcareWorkers/File,13577,en.pdf. Accessed October 2, 2014.

25. Dodhia H, Miller E. Review of the evidence for the use of erythromycin in the management of persons exposed to pertussis. Epidemiol Infect. 1998;120:143-149.

26. Altunaiji S, Kukuruzovic R, Curtis N, et al. Antibiotics for whooping cough (pertussis). Cochrane Database Syst Rev. 2007;(3):CD004404.

27. Prophylactic erythromycin for whooping-cough contacts. Lancet. 1981;1:772.

28. Halperin SA, Bortolussi R, Langley JM, et al. A randomized, placebo-controlled trial of erythromycin estolate chemoprophylaxis for household contacts of children with culture-positive bordetella pertussis infection. Pediatrics. 1999;104:e42.

29. Langley JM, Halperin SA, Boucher FD, et al; Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC). Azithromycin is as effective as and better tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics. 2004;114:e96-e101.

30. Tiwari T, Murphy TV, Moran J; National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep. 2005;54(RR-14):1-16.

Tx IS EFFECTIVE WHEN STARTED EARLY
Antibiotics are an effective treatment for pertussis, but they need to be started within the first few weeks of developing symptoms. Studies have not found evidence that antibiotics shorten the duration of pertussis symptoms unless they are given in the catarrhal phase.^22,23It can be challenging to get treatment started during this window, however, because patients may put off seeking care for symptoms they perceive as only minor, such as a cough, until the disease progresses. In addition, physicians may not suspect pertussis in patients who present with a cough they have had for only a short time, and therefore may not test for it.

It may be necessary to rely on clinical suspicion when deciding whether to initiate treatment for pertussis before testing to confirm the diagnosis. For patients in whom clinical suspicion of pertussis is high and who may be in contact with high-risk individuals, it may be acceptable to begin treatment before receiving lab test results.^24,25A recent Cochrane meta-analysis²⁶recommended initiating treatment to render a patient who has pertussis “noninfectious” but without an expectation of diminishing symptoms.

Limited role for prophylaxis. There is little evidence that prophylactic treatment for pertussis can decrease the spread of the disease. Studies that investigated potential benefits of prophylactic treatment for pertussis have been inconclusive, except for individuals who are in close contact with an infant younger than 6 months of age who has not been fully immunized.^27,28

A macrolide antibiotic is generally used to treat pertussis (TABLE 4).^25-30Consider starting treatment before lab results are  in when clinicial suspicion is high and the patient may be in contact with high-risk individuals. Erythromycin had been the drug of choice, but recent studies have found similar efficacy for azithromycin and clarithromycin.²⁹For infants younger than one month of age, azithromycin is preferred because in addition to being as effective as other macrolides, it has a better adverse effect profile.²⁹For patients who are at least 2 months of age, trimethoprim-sulfamethoxazole is an acceptable alternative to a macrolide.

The CDC recommends that any adolescent or adult who has a cough and has had close contact with an individual with a laboratory-confirmed case of pertussis within the past 21 days should be treated.³⁰Close contacts younger than 7 years of age who have not received the first 4 doses of the pertussis vaccine should be offered treatment.

CORRESPONDENCE
Gary Rivard, DO, Family Medicine Residency Program, Central Maine Medical Center, 76 High Street, Lewiston, ME 04282; rivardga@cmhc.org