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Pediatrics, Pertussis: Treatment & Medication
Updated: May 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- General supportive measures (eg, oxygenation, breathing treatments, mechanical ventilation) should be administered as needed.
- Infants should be carefully observed for apnea, cyanosis, or hypoxia.
- Patients should be isolated from susceptible individuals (especially infants) for 4 weeks, especially until 5-7 days of antibiotic therapy is completed. When patients present with paroxysmal cough, the clinical course is not shortened, but transmission is considerably decreased after 5 days of therapy.
- Factors that should prompt a consideration of admitting the patient are the following:
- Age younger than 1 year
- Pneumonia
- Apneic or cyanotic spells or hypoxia
- Moderate-to-severe dehydration
- The effectiveness of prophylaxis for exposed susceptible persons has not been determined; however, it is recommended for household and close contacts of the patient. Regimens include the following:
- Erythromycin 50 mg/kg/d divided 4 times a day (qid) for 14 days
- Alternative: Clarithromycin 7.5 mg/kg 2 times a day (bid) for 14 days (The effectiveness of clarithromycin has not been proven but is inferred.)
Consultations
Pertussis is a reportable infectious disease in the United States.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
Erythromycin is the antibiotic treatment of pertussis. If the patient is allergic to erythromycin, use trimethoprim sulfamethoxazole (TMP-SMZ).
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Erythromycin (Ilosone, EES)
Erythromycin estolate is antibiotic of choice to prevent interpersonal transfer, because of enhanced absorption, particularly in young infants. Effectiveness of prophylaxis for exposed and susceptible persons not determined; recommended for household and close contacts (50 mg/kg/d PO qid for 14 d). Effective in reducing course and symptoms if started within the first 10-14 d but not proven beyond this period. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis. For treatment of staphylococcal and streptococcal infections.
Adult
500 mg (as base) PO qid for 14 d; if estolate salt prescribed, administer for 7 d
Pediatric
Base: 40 mg/kg/d PO divided qid for 14 d; not to exceed 2 g/d
Estolate salt: 40 mg/kg/d PO divided q8-12h for 7 d; not to exceed 2 g/d
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Shown to be effective for pertussis in several small studies.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Pediatric
<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Clarithromycin (Biaxin)
Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl tRNA from ribosomes, causing bacterial growth inhibition.
Adult
500 mg PO bid for 7-10 d
Pediatric
15-20 mg/kg PO divided bid for 5-7 d; not to exceed 1 g/d
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, HMG-CoA reductase inhibitors
Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Trimethoprim and sulfamethoxazole (TMP-SMZ, Bactrim DS, Septra)
Second-line antibiotic (for erythromycin allergy or intolerability). Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Combination blocks 2 consecutive steps in bacterial biosynthesis of essential nucleic acids and proteins. In vitro, bacterial resistance develops more slowly with combination than with either drug alone.
Adult
160 mg TMP/800 mg SMZ PO q12h for 14 d
Pediatric
<2 months: Contraindicated
>2 months: 5-10 mg/kg/d (based on TMP component) PO divided bid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly patients; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency; age <2 mo
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may depress bone marrow (if signs occur, give leucovorin 5-15 mg/d); caution in folate deficiency (eg, patients with chronic alcoholism, elderly patients, those receiving anticonvulsants, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation
Vaccines
Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components that act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.
The need for prevention of pertussis through immunization cannot be overemphasized. Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. A case-control study identified 156 laboratory-confirmed pertussis cases over an 11-year period (matched controls n=595).2 Among the cases, 18 (12%) were pertussis vaccine refusers and among the controls 3 (0.5%) were vaccine refusers. Children of parents who refused pertussis immunizations were at an increased risk for pertussis compared with children of parents who accepted vaccinations. A secondary case-control analysis confirmed these results. The study was performed within the Kaiser Permanente of Colorado, where 11% of all pertussis cases within the Colorado Kaiser Permanente system were attributed to parental vaccine refusal. Herd immunity does not seem to completely protect unvaccinated children from pertussis.
All children younger than 7 years should receive the pertussis vaccine. In the United States, acellular pertussis vaccine is recommended and usually is combined with diphtheria and tetanus toxoids (DTaP). When possible, the same DTaP vaccine product should be used for the first 5 doses of the pertussis immunization series. Tdap is recommended as a one-time adolescent booster or for adults requiring tetanus immunization who did not have an adolescent booster. Reduced-volume dosing is not recommended. Measurable antibody wanes after 3-5 years and is not measurable 12 years after vaccination has been completed. Vaccine may not prevent the illness entirely, but it has been shown to lessen disease severity and duration.
Adolescents and adults have been identified as the source of pertussis transmission to infants, from household contact studies and outbreak investigations. Infectious disease experts are currently investigating the most efficacious and cost-effective means of preventing disease transmission to infants, who are at highest risk of severe disease. Options include vaccination of adolescents and adults in close contact with infants, maternal vaccination to provide passive antibody protection to the infant, and vaccinating infants with acellular pertussis vaccine at birth.
In December 2005, the American Academy of Pediatrics approved recommendations from the Committee on Infectious Diseases (COID) for universal vaccination of adolescents at the 11- or 12-year visit to boost protection against pertussis. The Food and Drug Administration (FDA) has licensed 2 tetanus toxoids (Td), reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) products, for use in children aged 10-18 years (Boostrix; GlaxoSmithKline Biologicals, Rixensart, Belgium) and in those aged 11-64 years (Adacel; Sanofi Pasteur, Toronto, Canada).
The latest vaccine recommendations can be found at the CDC Immunization Schedule Website.3
Diphtheria, tetanus and acellular pertussis (DTaP) vaccine (Tripedia, Certiva, Infanrix)
Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific antibodies and antitoxins.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.
Adult
0.5 mL IM diphtheria and tetanus toxoids (Td) and dose according to vaccine history
Pediatric
0.5 mL IM at 2, 4, 6, 15-18 mo, and 4-6 y
7-18 years catch-up schedule for primary immunization: 0.5 mL IM Td for 3 doses; allow 4 wk between dose 1 and 2, and 6 mo between dose 2 and 3; follow with booster dose 6 mo after 3rd dose (may substitute Tdap for booster dose if age appropriate)
Adolescent booster dose (10-18 years): Tdap 0.5 mL IM once as a single dose
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response (may defer immunization until treatment completed); cimetidine may enhance or augment delayed-hypersensitivity responses to skin test antigens; avoid concurrent use with systemic chloramphenicol because may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)
Documented hypersensitivity; history of neurologic symptoms or signs following DTaP administration
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Routine immunization of symptomatic and asymptomatic persons infected with HIV is recommended; may cause transient redness, swelling, or pain at site of injection; infrequently causes fever
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Adacel, Boostrix)
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster.
Adult
One-time alternative to Td in adults when pertussis component is also indicated: 0.5 mL IM once as a single dose into deltoid muscle; at least 5 y should elapse since last dose of tetanus-, diphtheria-, and/or pertussis-containing vaccine; booster with Td recommended q10y
>65 years: Not indicated
Pediatric
<10 years: Not indicated
10-18 years: Administer as in adults; preferred vaccine for adolescents scheduled for booster
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of a poor immune response
Documented hypersensitivity; encephalopathy within 7 d following pertussis-containing vaccine; progressive neurologic disorder, uncontrolled epilepsy, or progressive encephalopathy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Routine immunization of symptomatic and asymptomatic persons infected with HIV is recommended; may cause transient redness, swelling, or pain at injection site; infrequently causes fever; administer only if benefit outweighs risk to individuals with bleeding disorders (eg, hemophilia, thrombocytopenia) or those who are on anticoagulant therapy; caution if fever, shock, persistent crying, Guillain-Barré syndrome, or seizures occurred following previous DTP or DTaP vaccine (consider administering Td instead)
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| Overview: Pediatrics, Pertussis |
| Differential Diagnoses & Workup: Pediatrics, Pertussis |
 Treatment & Medication: Pediatrics, Pertussis |
| Follow-up: Pediatrics, Pertussis |
| References |
| Further Reading |
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References
Centers for Disease Control and Prevention. Outbreaks of respiratory illness mistakenly attributed to pertussis--New Hampshire, Massachusetts, and Tennessee, 2004-2006. MMWR Morb Mortal Wkly Rep. Aug 24 2007;56(33):837-42. [Medline]. [Full Text].
Glanz JM, McClure DL, Magid DJ, Daley MF, France EK, Salmon DA, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics. June 2009;123(6):1446-51. [Full Text].
Centers for Disease Control and Prevention. Immunization Schedules. Available at http://www.cdc.gov/vaccines/recs/schedules/default.htm. Accessed March 31, 2009.
[Guideline] Recommended childhood and adolescent immunization schedules--United States, 2009. Pediatrics. Jan 2009;123(1):189-90. [Medline].
[Guideline] Centers for Disease Control and Prevention. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five-dose series. (Addendum). 1997 guideline with 2000-2003 supplements. [Full Text].
[Guideline] American Academy of Pediatrics Commitee on Infectious Diseases. Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Pediatrics. Mar 2006;117(3):965-78. [Medline].
Aoyama T, Sunakawa K, Iwata S, et al. Efficacy of short-term treatment of pertussis with clarithromycin and azithromycin. J Pediatr. Nov 1996;129(5):761-4. [Medline].
Bass JW, Stephenson SR. The return of pertussis. Pediatr Infect Dis J. Feb 1987;6(2):141-4. [Medline].
Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule-United States, October 2007-September 2008. MMWR Morb Mortal Wkly Rep. Oct 19 2007;56(41):Q1-Q4. [Full Text].
Centers for Disease Control and Prevention. Recommended Immunization Schedules for Persons Aged 0--18 Years ---United States, 2008. MMWR. 2007;56(51&52):Q1-Q4.
Centers for Disease Control and Prevention. Vaccine preventable deaths and the Global Immunization Vision and Strategy, 2006-2015. MMWR Morb Mortal Wkly Rep. May 12 2006;55(18):511-5. [Medline]. [Full Text].
Geier DA, Geier MR. An evaluation of serious neurological disorders following immunization: a comparison of whole-cell pertussis and acellular pertussis vaccines. Brain Dev. Aug 2004;26(5):296-300. [Medline].
He Q, Viljanen MK, Arvilommi H, et al. Whooping cough caused by Bordetella pertussis and Bordetella parapertussis in an immunized population. JAMA. Aug 19 1998;280(7):635-7. [Medline].
Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and incidence of adult pertussis in an urban population. JAMA. Jun 5 1996;275(21):1672-4. [Medline].
Roush SW, Murphy TV,. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. Nov 14 2007;298(18):2155-63. [Medline].
Tindberg Y, Blennow M, Granstrom M. A ten year follow-up after immunization with a two component acellular pertussis vaccine. Pediatr Infect Dis J. Apr 1999;18(4):361-5. [Medline].
Ward JI, Cherry JD, Chang SJ, Partridge S, Lee H, Treanor J. Efficacy of an acellular pertussis vaccine among adolescents and adults. N Engl J Med. Oct 13 2005;353(15):1555-63. [Medline].
Wright SW, Edwards KM, Decker MD, Lamberth MM. Pertussis seroprevalence in emergency department staff. Ann Emerg Med. Sep 1994;24(3):413-7. [Medline].
Wright SW, Edwards KM, Decker MD, Zeldin MH. Pertussis infection in adults with persistent cough. JAMA. Apr 5 1995;273(13):1044-6. [Medline].
Further Reading
Clinical guidelines
Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five-dose series. (Addendum). Centers for Disease Control and Prevention. 1997 guideline with 2000-2003 supplements. 5
Prevention of pertussis among adolescents: recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. American Academy of Pediatrics. 2006. 6
Keywords
whooping cough, pertussis, Bordetella pertussis, B pertussis, pertussis vaccination, acellular vaccination, whole-cell vaccination, protracted cough, vaccine-preventable disease, cough in infants, whole-cell vaccine, acellular vaccine, DTaP, Tdap, Td booster, immunization schedule, vaccines
