eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pertussis: Follow-up

Author: Hazel Guinto-Ocampo, MD, Consulting Staff, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Emergency Medicine, Nemours Children's Clinic, AI duPont Hospital for Children
Coauthor(s): Bryon K McNeil, MD, Medical Director, Bioterrorism and Emergency Preparedness, Clinical Assistant Professor, Departments of Internal Medicine and Emergency Medicine, Via Christ Regional Medical Center; Stephen C Aronoff, MD, Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine
Contributor Information and Disclosures

Updated: May 27, 2009

Follow-up

Further Inpatient Care

  • Inpatient care is required for patients with pertussis who have intractable nausea and vomiting, failure to thrive, seizures, encephalopathy, or for patients with sustained hypoxemia during coughing paroxysms who require supplemental oxygen.
  • Therapy is largely supportive but should include macrolide administration and possible use of steroids, beta2-agonists, or both.
  • Antibiotics are most effective if started when the patient is in the catarrhal stage and may abort infection or at least make the patient noncommunicable. Antibiotics may also prevent or alleviate secondary bacterial infection.

Further Outpatient Care

  • Most patients older than 1 year can be treated on an outpatient basis if they do not fulfill the criteria for hospital admission (see Further Inpatient Care).
  • Frequent outpatient reevaluations are required; frequency of observation should be individualized based on the patient's age, disease severity, and presence of comorbid conditions.

Transfer

  • Transfer of patients is not usually indicated unless inpatient therapy and monitoring is warranted and such facilities are not available at the original institution.
  • Need for transfer should be evaluated on an individual basis.
  • Standard monitoring and transfer protocols should be followed.

Deterrence/Prevention

  • Prevention through immunization remains the best defense in the fight against pertussis.
  • Since nearly all of the fatal cases of pertussis occur in infants who were too young to have been immunized, novel strategies must be explored to protect these vulnerable young infants.
  • An option may be to immunize neonates with acellular pertussis vaccine. However, immunogenicity of the vaccine in newborns and possible induction of tolerance to B pertussis antigens need to be investigated.
  • Evidence is overwhelming that parents and older siblings are the primary source of infection in young infants. The incidence of pertussis in preadolescents, adolescents, and adults has increased, and may be responsible for the increasing number of cases observed in young infants in some countries. In December 2005, the American Academy of Pediatrics approved recommendations from the COID for universal vaccination of adolescents at the 11-year or 12-year visit to boost protection against pertussis.13 The FDA has licensed 2 tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) products, for use in children aged 10-18 years (Boostrix; GlaxoSmithKline Biologicals, Rixensart, Belgium) and 11-64 years (Adacel; Sanofi pasteur, Toronto, Canada). Tdap will replace tetanus toxoids in the childhood immunization schedule. The effectiveness of this strategy has yet to be demonstrated.

Complications

  • Complications of pertussis are usually minimal, and most patients make a gradual full recovery with supportive care and antibiotics.
  • Infants younger than 6 months with pertussis are more likely to have severe disease, to develop complications, and to require hospitalization. Major complications include pneumonia (20%), encephalopathy, seizures (1%), failure to thrive, and death (0.3%).
  • Minor complications during the illness include epistaxis, nausea and vomiting, subconjunctival hemorrhages, and ulcers of the frenulum.

Prognosis

  • Prognosis for full recovery is excellent; however, patients with comorbid conditions as previously described have a higher risk of morbidity and mortality and should be evaluated on an individual basis.
  • Compared with older children and adults, infants younger than 6 months with pertussis are more likely to have severe disease, to develop complications, and to require hospitalization. From 2001-2003, 69% of infants younger than 6 months with pertussis required hospitalization.2 Pneumonia, either from Bordetella pertussis infection or from secondary infection with other pathogens, is a relatively common complication, occurring in approximately 13% of infants with pertussis.4  CNS complications such as seizures and encephalopathy are less common and are thought to result from severe paroxysm-induced cerebral hypoxia and apnea, metabolic disturbances such as hypoglycemia, and small intracranial hemorrhages. Reported deaths due to pertussis in young infants have increased substantially over the past 20 years.5,6,7  From 1990-1999, the case fatality rate was approximately 1% in infants younger than 2 months and less than 0.5% in infants aged2-11 months.
  • Leukocytosis, particularly WBC counts of more than 100,000, has been associated with fatalities from pertussis. Another study showed that WBC counts of more than 55, 000 and pertussis complicated by pneumonia were independent predictors of fatal outcome in a multivariate model.

Patient Education

  • When a diagnosis of pertussis is made, patient and parent education and individualized supportive treatment are the best options.
  • All parents should receive information regarding the infectious and contagious potential of pertussis, as well as the risks derived from the vaccine.
  • Prevention of pertussis involves the use of vaccine approved by the FDA and standard infection control precautions.
  • For excellent patient education resources, visit eMedicine's Children's Health Center and Public Health Center. Also, see eMedicine's patient education articles Whooping Cough and Immunization Schedule, Children.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose pertussis: Potential for serious sequelae is noted. Death may occur in young infants and in patients with severe disease. Legal risks are observed as a result of the potential adverse effects of vaccines.
  • Failure to advise patients adequately regarding the need for further observation and the risks of infection

Special Concerns

  • Young infants have the highest risk for complications and death and require close observation or hospitalization.
  • Control measures should be implemented immediately when one or more cases of pertussis are recognized in health care settings such as in a hospital, institution, or outpatient clinic. Confirmed and suspected cases should be reported to the local health departments, and their involvement in control measures should be sought.
 


More on Pertussis

Overview: Pertussis
Differential Diagnoses & Workup: Pertussis
Treatment & Medication: Pertussis
Follow-up: Pertussis
Multimedia: Pertussis
References
[ CLOSE WINDOW ]

References

  1. Cherry JD, Heininger U. Pertussis and other Bordetella Infections. In: Feigin RD, Demmler GJ, Cherry JD, Kaplan SL. Textbook of Pediatric Infectious Diseases. Vol 1. 5th ed. Philadelphia, PA: WB Saunders Co.; 2004:1588-1608.

  2. Pertussis--United States, 2001-2003. MMWR Morb Mortal Wkly Rep. Dec 23 2005;54(50):1283-6. [Medline].

  3. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years - United States, 2008. MMWR. 2008;57(1):Q1-Q4. [Full Text].

  4. Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestations of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev. Apr 2005;18(2):326-82. [Medline].

  5. [Guideline] Bisgard K. Background. Guidelines for the Control of Pertussis Outbreaks. 2000;1-1-1-11. [Full Text].

  6. Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J. Jul 2003;22(7):628-34. [Medline].

  7. Centers for Disease Control. Pertussis. In: Atkinson W, Hamborsky J, McIntyre L, Wolfe S. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Washington DC: Public Health Foundation; 2007:80-96. [Full Text].

  8. Centers for Disease Control and Prevention. Pertussis--United States, 1997-2000. MMWR Morb Mortal Wkly Rep. Feb 1 2002;51(4):73-6. [Medline].

  9. Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source?. Pediatr Infect Dis J. Nov 2004;23(11):985-9. [Medline].

  10. Edwards K, Decker MD. Pertussis vaccine. In: Plotkin SA, Orenstein WA. Vaccines. 4th ed. Philadelphia, PA: Saunders; 2004:471-528.

  11. Guinto-Ocampo H, Bennett JE, Attia MW. Predicting pertussis in infants. Pediatr Emerg Care. Jan 2008;24(1):16-20. [Medline].

  12. American Academy of Pediatrics. Pertussis. In: Pickering LK, ed. Red Book: 2006 Report of the Committee of Infectious Disease. 2006:498-520.

  13. American Academy of Pediatric Committee 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].

  14. [Best Evidence] Glanz JM, McClure DL, Magid DJ, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics. Jun 2009;123(6):1446-51. [Medline]. [Full Text].

  15. Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics. May 2005;115(5):1422-7. [Medline]. [Full Text].

  16. Crowcroft NS, Stein C, Duclos P, Birmingham M. How best to estimate the global burden of pertussis?. Lancet Infect Dis. Jul 2003;3(7):413-8. [Medline].

  17. Decker MD, Edwards KM. Acellular pertussis vaccines. Pediatr Clin North Am. Apr 2000;47(2):309-35. [Medline].

  18. Edwards KM, Halasa N. Are pertussis fatalities in infants on the rise? What can be done to prevent them?. J Pediatr. Nov 2003;143(5):552-3. [Medline].

  19. Guris D, Strebel PM, Bardenheier B, et al. Changing epidemiology of pertussis in the United States: increasing reported incidence among adolescents and adults, 1990-1996. Clin Infect Dis. Jun 1999;28(6):1230-7. [Medline].

  20. Jajosky RA, Hall PA, Adams DA, et al. Summary of notifiable diseases--United States, 2004. MMWR Morb Mortal Wkly Rep. Jun 16 2006;53(53):1-79. [Medline].

  21. Kretsinger K, Broder KR, Cortese MM, et al. 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 health-care personnel. MMWR Recomm Rep. Dec 15 2006;55:1-37. [Medline].

  22. Long S. Academy issues policy on adolescent pertussis vaccine. AAP News. 2006;27:1.

  23. Long S. Pertussis (Bordetella pertussis and B parapertussis). In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. Vol 17. 2004:908-12.

  24. Lutwick LI, Rubin LG. Childhood immunizations 2000. Introduction. Pediatr Clin North Am. Apr 2000;47(2):xi-xiv. [Medline].

  25. McNabb SJ, Jajosky RA, Hall-Baker PA, Adams DA, Sharp P, Anderson WJ, et al. Summary of notifiable diseases --- United States, 2005. MMWR Morb Mortal Wkly Rep. Mar 30 2007;54(53):1-92. [Medline].

  26. McNabb SJ, Jajosky RA, Hall-Baker PA, Adams DA, Sharp P, Worshams C, et al. Summary of notifiable diseases--United States, 2006. MMWR Morb Mortal Wkly Rep. Mar 21 2008;55(53):1-92. [Medline].

  27. Mikelova LK, Halperin SA, Scheifele D, et al. Predictors of death in infants hospitalized with pertussis: a case-control study of 16 pertussis deaths in Canada. J Pediatr. Nov 2003;143(5):576-81. [Medline].

  28. Pierce C, Klein N, Peters M. Is leukocytosis a predictor of mortality in severe pertussis infection?. Intensive Care Med. 2000;159:898-900. [Medline].

  29. Tanaka M, Vitek CR, Pascual FB, et al. Trends in pertussis among infants in the United States, 1980-1999. JAMA. Dec 10 2003;290(22):2968-75. [Medline].

  30. Tiwari T, Murphy TV, Moran J. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines. MMWR Recomm Rep. Dec 9 2005;54:1-16. [Medline].

  31. Tozzi AE, Celentano LP, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ. Feb 15 2005;172(4):509-15. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pertussis, whooping cough, coughing, infectious diseases, respiratory tract infection, Bordetella pertussis infection, B pertussis infection, Bordetella parapertussis infection, B parapertussis infection, pneumonia, prematurity, seizures, syncope, hypoglycemia, sudden infant death, upper respiratory infection, nasal congestion, rhinorrhea, sneezing, headache, posttussive vomiting

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Hazel Guinto-Ocampo, MD, Consulting Staff, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Emergency Medicine, Nemours Children's Clinic, AI duPont Hospital for Children
Hazel Guinto-Ocampo, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Bryon K McNeil, MD, Medical Director, Bioterrorism and Emergency Preparedness, Clinical Assistant Professor, Departments of Internal Medicine and Emergency Medicine, Via Christ Regional Medical Center
Bryon K McNeil, MD is a member of the following medical societies: American Academy of Emergency Medicine and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Stephen C Aronoff, MD, Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine
Stephen C Aronoff, MD is a member of the following medical societies: Pediatric Infectious Diseases Society and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Gary J Noel, MD, Department of Pediatrics, Clinical Associate Professor, Weill Medical College of Cornell University
Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.