Pediatric Pertussis Medication

Antimicrobial agents given during the catarrhal phase may ameliorate the disease. Once cough is established, antimicrobial agents may not alter the course of the illness but are still recommended to limit the spread of disease.

Pertussis-specific immune globulin is an investigational product that may be effective in decreasing paroxysms of cough but requires further evaluation.

The use of corticosteroids, albuterol, and other beta2-adrenergic agents for the treatment of pertussis is not supported by controlled, prospective data.

Class Summary

The Committee on Infectious Diseases of the American Academy of Pediatrics (Red Book Committee) currently recommends promptly treating all household and other close contacts (eg, children and staff at daycare centers) with erythromycin to limit secondary transmission.^[13] This is regardless of the age or immunization status of contacts. A 14-day course of oral (PO) erythromycin is the antimicrobial therapy of choice for patients with pertussis and for close contacts. Typical dosing schedule is 40-50 mg/kg/d (not to exceed 2 g/d) in 4 divided doses. Some experts prefer the estolate preparation in young infants because of more effective absorption, which may lead to decreased dosing and less frequent dosing intervals.

In infants younger than 2 weeks, an association between orally administered erythromycin and infantile hypertrophic pyloric stenosis (IHPS) has been reported. Because pertussis can be life threatening in neonates and the efficacy of alternative therapies has not been well studied, the American Academy of Pediatrics continues to recommend the use of erythromycin for treatment of and prophylaxis for pertussis. Parents and caregivers need to be informed about the risks and signs of IHPS.

The newer macrolides (eg, azithromycin [Zithromax], clarithromycin [Biaxin]), are potential alternatives for patients who cannot tolerate erythromycin. Azithromycin is typically administered in doses of 10-12 mg/kg/d PO in 1 dose for a total of 5 days. Clarithromycin is administered at 15-20 mg/kg/d PO in 2 divided doses, not to exceed 1 g/d for 5-7 days. Trimethoprim-sulfamethoxazole (Bactrim) is another antibiotic option, with the following dosage: trimethoprim 8 mg/kg/d and sulfamethoxazole 40 mg/kg/d in 2 divided doses.

Erythromycin (EES, E-Mycin, Eryc, Ery-Tab, Erythrocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Azithromycin (Zithromax)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Shown to be effective for pertussis in several small studies.

Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Shown to be effective for pertussis in recent small studies.

Trimethoprim-sulfamethoxazole (Bactrim, Septra, Cotrim)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Alternative drug, but efficacy is unproven for pertussis.

Class Summary

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. 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 3 doses of the pertussis immunization series. Reduced-volume dosing is not recommended. Measurable antibody wanes after 3-5 years and is not measurable 12 years after vaccination has been completed. The vaccine may not prevent the illness entirely but 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. In February 2012, the CDC Advisory Committee on Immunization Practices (ACIP) recommended the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine for all adults, including those aged 65 years or older, and pregnant women.

A Cochrane Database of Systematic Reviews study compared the safety and efficacy of whole-cell pertussis vaccines compared with acellular pertussis vaccines in children up to 6 years old. The results showed that not only are multi-component acellular pertussis vaccines effective, they show less adverse effects than whole-cell vaccines for both the primary and booster doses.^[14]

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-year or 12-year visit to boost protection against pertussis.^[15] 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 aged 11-64 years (Adacel; Sanofi Pasteur, Toronto, Canada). Tdap will replace Td in the childhood immunization schedule. The effectiveness of this strategy has yet to be demonstrated.

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).^[16] Among the cases, 18 (12%) children did not receive the pertussis vaccine; among the controls, 3 (0.5%) children did not receive the pertussis vaccine. 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.

DTaP (Tripedia, Certiva, Infanrix)

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.

Tdap (Adacel, Boostrix)

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis 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.