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PERTUSSIS
MEAGHAN MOLLARD
DEFINITION
• “Whooping cough”
• Highly contagious, acute respiratory illness cause by
Bordetella pertussis bacteria
• Most commonly affects children <6 months of age who are
not completely vaccinated and children 11-12 years as
childhood vaccination coverage wears off
• Inspiratory whoop
• Paroxysmal cough
• Post-tussive emesis
(CDC, 2014)
ETIOLOGY
• B. pertussis is caused by gram negative
pleomorphic bacillus
• Pertussis is highly contagious infecting 80-90% of
susceptible individuals that are exposed
• 3 Species of Bordetella can affect respiratory tract
• B. parapertussis, B. bronchiseptica, B. holmesii
(Bocka, 2014)
PATHOPHYSIOLOGY
• Pertussis is primarily a toxin-mediated disease.
• Bacteria attach to the cilia of the respiratory
epithelial cells.
• Bacteria produce toxins that paralyze the cilia
causing inflammation of the respiratory tract.
• Inflammation interferes with the clearing of
pulmonary secretions.
• Pulmonary secretions are described as a
mucopurulosanguineous exudates.
(Bocka, 2014)
TRANSMISSION
• Spread from person to person when coughing, sneezing,
talking, and laughing while in close contact.
• Inhalation of infected respiratory droplets.
• Many infants and children who are not fully vaccinated
are infected by older siblings, parents and caregivers.
• Contagious from the onset of cold like symptoms
through 3rd week, after paroxysmal coughing onset, or
until after 5 days of effective antibiotic treatment.
(CDC, 2014)
INCUBATION
• Incubation period can be as short as one week but
as long as 3 weeks
• Typically 7-10 days
• Incubation period is longer than that of the
common cold, which is about 1 to 3 days
(Bocka, 2014)
INCIDENCE
• 48.5 million yearly cases world wide
• 4,838 cases of pertussis reported from January 1, 2014 to
April 14, 2014
• High infant mortality rate prior to whole cell vaccine in
the 1940’s.
• Cyclical epidemics every two to five years, present in the
pre-vaccine era
• Most cases occur in late summer and early fall
• 5-10% of cases are recognized and reported
• Most commonly reported vaccine-preventable disease
in the United States in children younger than 5 years.
(Bocka, 2014), (CDC, 2014)
FIGURE 1: REPORTED CASES OF
PERTUSSIS FROM 1922- 2013 (CDC, 2014)
REDUCE THE RISK
• Prevention: GET VACCINATED!!!
• Recommendations for infants and children:
• 5 doses of diphtheria, tetanus and pertussis (DTaP) vaccine
given between 6 weeks and 7 years of age, usually at 2
months, 4 months, 6 months, between 15-18 months and 4-6
years. (CDC, 2014), (Cornia & Lipsky, 2014)
REDUCE THE RISK
• Vaccine recommendation for children >7 and
adults:
• Tdap given between 11-18 years old, preferred
administration is between 11-12 years
• Adults 19 and older who have not had Tdap vaccine need
a booster shot
• Tdap administered to pregnant individuals during each
pregnancy between 27- 36 weeks gestation
• Td every 10 years
(CDC, 2014), (Cornia & Lipsky, 2014)
RISK FACTORS
• Young infants born prematurely
• Patients with underlying cardiac, pulmonary,
neuromuscular, or neurologic disease
• Non-vaccinated individuals
• Contact with an infected person
• Epidemic exposure
• Pregnancy
(Cornia & Lipsky, 2014)
SCREENING
• Vaccination screening should be done routinely at
primary care visits
• Screen:
• High risk individuals- infants, pregnant women, and non
vaccinated children
• OR
• Individuals who have had cough >2 weeks
CLINICAL FINDINGS
• Incubation period 7-10 days after exposure to B.
pertussis
• Followed by the onset of nonspecific symptoms
• Total duration of pertussis is about 3 months
• “The cough of 100 days.”
• 3 stages of Pertussis:
• Catarrhal
• Paroxysmal
• Convalescent
(Yeh & Mink, 2014), (CDC, 2014)
CLINICAL FINDINGS- CATARRHAL
• Lasts 1-2 weeks
• Pertussis most infectious during catarrhal phase
• Indistinguishable from common upper respiratory
infections
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Nasal Congestions
Rhinorrhea
Sneezing
Occasional low grade fever
Occasional cough
Red, watery eyes
Apnea in infants
(Yeh & Mink, 2014), (CDC, 2014)
CLINICAL FINDINGS- PAROXYSMAL
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Stage lasts 2 to 6 weeks
Paroxysmal attacks
Characteristic “Whoop”
Posttussive emesis
Extreme fatigue
(Yeh & Mink, 2014), (CDC, 2014)
CLINICAL FINDINGS- CONVALESCENT
• 3rd and final stage, lasts 1-2 weeks
• Gradual reduction in the frequency and severity of
cough
• Cough usually disappears after 2-3 weeks
• Coughing symptoms can reappear with subsequent
upper respiratory infections during the
convalescence phase
(Yeh & Mink, 2014), (CDC, 2014)
DIFFERENTIAL DIAGNOSIS
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Mycoplasma pneumoniae
Chlamydia pneumoniae
Adenoviruses
Respiratory syncytial virus infection
• (Bocka, 2014)
DIFFERENTIAL DIAGNOSIS
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Common cold
Influenza
Interstitial pneumonitis
Bronchiolitis
Croup
Dehydration
Aspiration pneumonia
Bacterial pneumonia
Viral pneumonia
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Febrile Seizures
Fever
Gastroenteritis
Tachycardia
Tuberculosis
(Bocka, 2014)
SOCIAL/ENVIRONMENTAL
CONSIDERATIONS
• Social:
• Get vaccinated
• High risk patients like infants and immuno-compromised
individuals should avoid potential exposure
• Drink plenty of fluids
• Adequate rest
Environmental:
• Be aware of stimuli that can trigger coughing fits, ie:
laughing, talking
• Keep air clean and free from triggers, ie: tobacco smoke
DIAGNOSIS
• Detailed history
• potential exposure to pertussis from infected individuals
• common signs and symptoms associated with pertussis
• Duration of symptoms
• Physical exam
• Rule out other potential causes of signs and symptoms
• Most common physical findings include:
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conjunctival hemorrhage
facial petechiae
(Bocka, 2014)
LABORATORY TESTS
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Nasopharyngeal culture
PCR and Elisa
Serology Testing
CBC trend
• The CDC recommends a combination of a culture and PCR
assay if a patient has a cough lasting longer than 3 weeks.
(CDC, 2014)
MANAGEMENT
• Goals of treatment
• Limit the number of paroxysms
• Maximize nutrition, rest, and recovery
• Practice good hand hygiene to prevent the spread
of respiratory illnesses
TREATMENT
• Starting treatment within first 1-2 weeks of symptom onset
before paroxysmal cough starts might decrease the severity of
symptoms. (Bocka, 2014)
• CDC suggests treating prior to test results if clinical history
strongly suggestive or if high risk patient, ie: infants. (CDC, 2014)
• If patient diagnosed late, ABX will not change course of illness
and should only be treated with an ABX if still contagious.
(Bocka, 2014)
TREATMENT
• Treatment indications:
• Antimicrobial tx with B.Pertussis isolated from culture or +
PCR
• Patient with a clinical diagnosis who has had symptoms for
less than 21 days
• Antimicrobial therapy for pt.’s who have >21 days of
symptoms, especially those in contact with high risk
individuals.
• The Committee on Infectious Diseases (COID) of the American
Academy of Pediatrics (Red Book Committee) recommends
treating household members of infected individuals to limit
secondary infection.
(CDC, 2014)
PHARMACOLOGICAL MANAGEMENT
Antimicrobial agents and antibiotics help to eradicate B pertussis and prevent
spreading
Macrolides: Erythromycin, Azithromycin, Clarithromycin
• Azithromycin preferred for infants <1 month
• Erythromycin administered for 14 days
• Azithromycin administered for 5 days
• Clarithromycin administered for 7 days
Trimethoprim-sulfamethoxazole alternative agent for persons >2months who
can not tolerate macrolides
• Bactrim is administered for 14 days
(Yeh, 2014), (CDC, 2014), (Bocka, 2014)
NON-PHARMACOLOGICAL
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Rest
Drink plenty of fluids
Eat smaller, more frequent meals
Vaporize the room
Keep the air clean
Prevent transmission
(CDC, 2014)
COMPLICATIONS
• Related the infection:
• Pneumonia
• Otitis Media
• Reintroduction of paroxysmal coughing with upper respiratory infections
• Sequelae of severe cough:
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Subconjunctival hemorrhage
Development or exacerbation of abdominal wall hernia
Rib fractures
Loss of bladder control
Weight loss, loss of appetite
Dehydration
Bloody nose
Hemoptysis
Cerebral hemorrhage,
Encephalopathy
Seizures
(Bocka, 2014), (CDC, 2014),
FOLLOW-UP
• Most patients older than 1 year can be treated on
an outpatient basis if they do not fulfill the criteria
for hospital admission
• Hospital admission is warranted for respiratory distress,
pneumonia, inability to feed, apnea, and seizures
• Frequent outpatient re-evaluations are required
• frequency based on the patient's age, disease severity, and
presence of comorbid conditions.
(Bocka, 2014)
COUNSELING/EDUCATION
• Education regarding importance of vaccination
administration *key to prevention*
• Review risks associated with vaccine
• Provide information regarding the infectious and
contagious potential of pertussis
• Seek medical attention if exposed for preventative
antibiotics
• Practice good hand hygiene
• Avoid contact with high risk patients for at least 5
days after treatment initiation if diagnosed with B.
pertussis
CONSULTATION/REFERRAL
• Consultation with subspecialists is usually not
indicated
• Unless….
• The diagnosis is unclear
• Infectious disease consultation
• (Bocka, 2014)
QUESTION 1
• What is the macrolide used in infants <1 month?
A. Erythromycin
B. Azithromycin
C. Clarithromycin
ANSWER
• B: Azithromycin is preferred in infants <1 month of age,
unknown reaction with erythromycin and clarithromycin. Increased
potential of pyloric stenosis with the use of erythromycin. Less side
effects noted with azithromycin (Cornia & Lipsky, 2014)
QUESTION 2
• What antibiotic can be used in the treatment of
pertussis instead of a macrolide?
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A. Azithromycin
B. Amoxicillin
C. TMP-SMZ
D. Ceftriaxone
ANSWER
C: TMP-SMZ: trimethoprim-sulfamethoxazole is an alternative
agent for persons >2months who can not tolerate macrolides
Infants: trimethoprim 8 mg/kg per day, sulfamethoxazole 40
mg/kg per day in 2 divided doses for 14 days.
Adults: trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg
per day in 2 divided doses for 14 days. (Bocka, 2014)
QUESTION 3
• How many vaccines are included in the diphtheria,
tetanus, and pertussis (DTaP) series and at what
ages are they administered?
• A. 5 injections at birth, 6 months, 1 year, 18 months,
and 2 years
• B. 5 injections at 2, 4, 6 months, between 15-18
months and 4-6 years
• C. 3 injections at birth, 1 year, and 2 years
• D. 3 injections at 2, 6, 12 months
ANSWER 3
• B: DTaP is given in a series of 5 injections between 6
weeks and 7 years of age. Given at 2 months, 4
months, 6 months, between 15-18 months and
between 4-6 years of age. (CDC, 2014)
QUESTION 4
• How long should individuals with Pertussis avoid
contact with other individuals after starting
antibiotics?
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A. 24 hours
B. 3 days
C. 5 days
D. 7 days
ANSWER
• C. Patients with B. pertussis should avoid contact
with young children and infants until after they have
completed 5 days of antibiotics. (Cornia & Lipsky,
2014)
QUESTION 5
• Pregnant women can not get vaccinated
with Tdap during pregnancy.
• True or false?
ANSWER
• False
•
It is recommended that women get vaccinated
with Tdap during each pregnancy preferably
between 27-36 weeks gestation (CDC, 2014)
QUESTION 6
• What test is the gold standard used by clinician’s to
diagnose B. pertussis
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A. PCR
B. Blood culture
C. Nasopharyngeal culture
D. Serology Testing
ANSWER
• C: Nasopharyngeal culture is the gold standard for
identifying pertussis because it is a 100% specific.
Results take 5-7 days. (CDC, 2014)
• Best to collect sample within two weeks of symptom
onset when viable bacteria are still present in the
nasopharynx. After 2 weeks sensitivity is decreased
and the risk of false-negatives increases. (CDC,
2014)
QUESTION 7
• What is true about B. pertussis?
• A. It does not affect adults over the age of 65.
• B. Parents don’t need to get vaccinated if they vaccinate
their children
• C. It is the most commonly reported vaccine preventable
illness in individuals less than 5 years old.
ANSWER
• C: Pertussis can affect individuals over the age of
65, they more frequently hospitalized than
individuals between 11 and 64.
• Parents who are in close contact with children need
to get vaccinated despite vaccination status of
other individuals. Adolescents and adults usually
infect infants unknowingly.
• Pertussis is a nationally reported illness, and the CDC
states that is it the most commonly reported
vaccine preventable illness in children less than 5.
(CDC, 2014)
QUESTION 8
• What is the best way to prevent B pertussis?
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A. Avoid contact with potentially infected individuals
B. Vaccination
C. Stay away from children
D. Wash hands routinely
ANSWER
• B: The CDC states, “The best way to prevent
pertussis (whooping cough) among infants,
children, teens, and adults is to get vaccinated.”
(CDC, 2014)
QUESTION 9
• What is the most significant clinical finding in the
second phase of B. pertussis?
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A. Fever
B. Malaise
C. Runny nose
D. Paroxysmal cough
ANSWER
• D: Fever and runny nose are both clinical findings in
the catarrhal phase
• Malaise is a finding in the second phase but the
malaise is typically a side effect related to the
paroxysmal coughing fits(Cornia & Lipsky, 2014)
QUESTION 10
• What is the most common complication of B.
Pertussis?
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A. Pneumonia
B. Rib Fractures
C. Seizure
D. Dehydration
ANSWER
• A: Pneumonia is the most common complication of
B. pertussis, affecting about 1 in 20 individuals who
are infected (CDC, 2014), (Bocka, 2014)
REFERENCES
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Bocka, J. (2014). Pertussis. Retrieved on October 6, 2014 from
http://emedicine.medscape.com/article/967268-overview.
Cornia, P. & Lipsky, B.A. (2014 April 9). Treatment and prevention of bordetella pertussis infection
in adolescents and adults. Retrieved October 3, 2014, from
http://www.uptodate.com/contents/treatment-and-prevetion-of-bodretella-pertussis.
Cornia, P. & Lipsky, B.A. (2014 February 4). Microbiology, epidemiology, and pathogenesis of
bardetella pertussi infection. Retrieved October 3, 2014, from
http://www.uptodate.com/contents/microbiology-epidemiology-and-pathogenesis.
Cornia, P., & Lipsky, B.A. (2014 March 13). Clinical manifestations and diagnosis of bardetlla
pertussi infections in adolescents and adults. Retrieved October 3, 2014, from
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-bodetella.
Drutz, J.E.(2014, July14). Diphtheria, tetanus, and pertussis immunization in infacts and children 0
through 6 years of age. Retrieved on October 3, 2014 from
http://www.uptodate.com/contents/diphtheria-tetanus-and-pertussis.
Centers for Disease Control and Prevention. (2014). Pertussis, whooping cough. Retrieved on
October 3, 2014 from http://www.cdc.gov/pertussis.
MayoClinic. (2013). Whooping cough. Retrieved on October 6, 2014 from
http://www.mayoclinic.org/diseases-conditions/whooping-cough/basics.
Yeh, S. & Mink, C.M. (2014, June 17). Bordetella pertussis infection in infants and children: Clinical
features and diagnosis. Retrieved October 3, 2014, from
http://www.uptodate.com/contents/bordetella-infection-in-infants-and-children.
Yeh, S. (2014, April 9). Treatment and prevention of bordetella pertussis in adolescents and
adults. Retrieved October 3, 2014, from http://www.uptodate.com/contents/treatmentprevention-of-bordetlla-pertussis-infection.