Background

Pertussis, commonly known as whooping cough, is a respiratory tract infection characterized

by a paroxysmal cough. It was first identified in the 16th century. In 1906, Bordet isolated the
most common causative organism, Bordetella pertussis.Bordetella parapertussis has also
been associated with whooping cough in humans (see the image below). (See Etiology and
Pathophysiology.)

A photomicrograph of the
bacterium Bordetella pertussis, using Gram stain technique.
In the prevaccination era, pertussis (ie, whooping cough) was a leading cause of infant death.
As a result of vaccination, however, the number of cases reported decreased by more than
99% from the 1930s to the 1980s. Nonetheless, because of many local outbreaks, the number
cases reported in the United States increased by more than 2300% between 1976 and 2005.
(See Epidemiology.) [3]
The disease is still a significant cause of morbidity and mortality in infants younger than 2
years. Pertussis should be included in the differential diagnosis of protracted cough with
cyanosis or vomiting, persistent rhinorrhea, and marked lymphocytosis. (See Prognosis, DDx,
Presentation, and Workup.) [4]
Complications of pertussis can include the following (see Prognosis, Treatment, and
Medication):
 Pneumonia
 Hypoxic encephalopathy
 Otitis media
 Tuberculosis activation
 Epistaxis, hemoptysis
 Hernia
 Reinduction of paroxysmal coughing with upper respiratory infections
 Seizures
 Cerebral hemorrhage
 Coma and death
Etiology and Pathophysiology
Humans are the sole reservoir for B pertussis and B parapertussis. B pertussis, a gram-
negative pleomorphic bacillus, is the main causative organism for pertussis. (B
parapertussis is less common than B pertussis and produces a clinical illness that is similar
to, but milder than, that produced by B pertussis.) B pertussis spreads via aerosolized droplets
produced by the cough of infected individuals, attaching to and damaging ciliated respiratory
epithelium. B pertussis also multiplies on the respiratory epithelium, starting in the
nasopharynx and ending primarily in the bronchi and bronchioles. [5]
Pertussis is highly contagious, developing in approximately 80-90% of susceptible
individuals who are exposed to it. Most cases occur in the late summer and early fall.
A mucopurulent sanguineous exudate forms in the respiratory tract. This exudate
compromises the small airways (especially those of infants) and predisposes the affected
individual to atelectasis, cough, cyanosis, and pneumonia. The lung parenchyma and
bloodstream are not invaded; therefore, blood culture results are negative.
Transmission of pertussis can occur through direct face-to-face contact, through sharing of a
confined space, or through contact with oral, nasal, or respiratory secretions from an infected
source. In a study of pertussis in 4 US states, out of 264 infants with the disease, the infant’s
mother was the source of pertussis in 32% of cases, and another family member was the
source in 43% of cases. [6]
Although mothers have historically been the most common source of transmission of
pertussis to their infant, data from a study found that the most common source of
transmission to infants is through their siblings. [7, 8]
Young infants, especially those born prematurely, and patients with underlying cardiac,
pulmonary, neuromuscular, or neurologic disease are at high risk for contracting the disease
and for complications.
Risk factors for pertussis include the following:
 Nonvaccination in children
 Contact with an infected person
 Epidemic exposure
 Pregnancy
An Australian study of adult risk factors for pertussis found not only that persons aged 65
years or older were more likely than those aged 45-64 years to be hospitalized for pertussis,
but that adults with obesity or preexisting asthma had a greater likelihood of being diagnosed
with pertussis. (The investigators did not see a link between the pertussis incidence and age.)
The population-based, prospective, cohort study involved 263,094 adults aged 45-64 years. [9]

Epidemiology
Occurrence in the United States

Since the early 1980s, pertussis incidence has cyclically increased, with
peaks occurring every 2-5 years. [10] Most cases occur between June and
September. Neither acquisition of the disease nor vaccination provides
complete or lifelong immunity. Protection against typical disease wanes 3-5
years after vaccination and is not measurable after 12 years. [11, 12, 13]
The rate of pertussis peaked in the 1930s, with 265,269 cases and 7518
deaths reported in the United States. This rate decreased to a low of 1010
cases in the United States, with 4 deaths, in 1976. Starting in the 1980s,
however, the reported incidence of US pertussis cases dramatically
increased across all age groups. Although the largest increase in pertussis
cases has been among adolescents and adults, the annual reported
incidence has been highest among infants younger than 1 year. [14]
In 2010, according to the Centers for Disease Control and Prevention
(CDC), the US pertussis rate reached 27,550 cases (the highest number
since 1959), with 27 related deaths. [15, 16]
In 2011, according to preliminary statistics from the CDC, adolescents
(ages 11-19 years) and adults together accounted for 47% of pertussis
cases, while children aged 7-10 years accounted for 18% of cases. [16, 17]
According to the CDC, during the first half of 2012, most states had
reported either increased pertussis activity or outbreaks of the disease. By
July 5 of that year, 37 states had reported increases in pertussis cases
over those reported during the same period in 2011.
For example, as listed by the CDC and the states’ health departments, the
number of reported cases in Washington State (where a pertussis epidemic
was declared), Minnesota, and Wisconsin in 2012 were as follows [16] :
 Washington State - 2012: 3400 cases reported through Aug 4; 2011:
287 cases reported through Aug 4
 Minnesota - 2012: 2039 cases reported as of Aug 2; 2011 (entire
year): 661 cases reported
 Wisconsin - 2012: 3496 confirmed or probable cases reported through
July 31, 2012; 2011 (entire year): 1192 confirmed or probable cases
reported
The CDC listed a provisional national figure of 17,000 pertussis cases
between Jan 1 and July 21, 2012, including 9 pertussis-related deaths. The
reasons that pertussis cases peak in some years is not completely
understood, according to the CDC. [16]
The CDC has estimated that 5-10% of all cases of pertussis are recognized
and reported. Pertussis remains the most commonly reported vaccine-
preventable disease in the United States in children younger than 5 years.
In studies, 12-32% of adults with prolonged (1-4 wk) cough have been
found to have pertussis.
Between January 1, 2014 and June 10, 2014 California's public health
department reported 3,458 cases of pertussis. The department declared
the outbreak to have reached epidemic proportions, with 800 cases
reported in the span of just 2 weeks.[18] A study that examined a similar
outbreak in California in 2010 determined that nonmedical vaccine
exemptions played a role. [19]
Nationally, the CDC stated that the 4,838 cases of pertussis reported from
January 1, 2014 to April 14, 2014 represented a 24% increase over the
same period in 2013.[20]
The CDC reports that during January 1–November 26, 2014, a total of
9,935 cases of pertussis with onset in 2014 were reported in California.
Severe and fatal disease occurs almost exclusively in infants who are too
young to be vaccinated against pertussis. Therefore, pregnant women are
encouraged to receive tetanus, diphtheria, and acellular pertussis vaccine
(Tdap) during the third trimester of each pregnancy to provide placental
transfer of maternal antibodies to the infant. [21, 22]
International occurrence

The annual worldwide incidence of pertussis is estimated to be 48.5 million

cases, with a mortality rate of nearly 295,000 deaths per year. [23] The case-
fatality rate among infants in low-income countries may be as high as
4%. [24]
In England, the percentage of people vaccinated for pertussis over the last
4 decades has decreased to less than 30%. This decline has resulted in
thousands of recently reported cases of the disease, with the incidence rate
approaching that of the prevaccination era. Similar epidemic outbreaks
have recently occurred in Sweden, Canada, and Germany. Nearly 300,000
deaths from pertussis are thought to have occurred in Africa over the last
decade.
Race- and sex-related demographics

With regard to race, the CDC reported that among individuals with
pertussis between 2001 and 2003, 90% were white, 7% were black, 1%
were Asian/Pacific Islander, and 1% were American Indian/Alaska Native,
and 1% were identified as “other race”. From 2001-2003, females
accounted for 54% of pertussis cases in the United States. [25]
Age-related demographics

From 2001-2003, of patients with pertussis, 23% were younger than 1 year,
12% were aged 1-4 years, 9% were aged 5-9 years, 33% were aged 10-19
years, and 23% were older than 20 years. [26, 25]
Because of the lack of maternal immunity transfer, 10-15% of all cases of
pertussis occur in infants younger than 6 months; more than 90% of all
deaths occur in this same age group. However, the growing majority of
cases are now in persons aged 10 years and older, which has led to
increased booster recommendations.

Prognosis
Prognosis for full recovery from pertussis is excellent in children over 3
months of age. In those less than 3 months the mortality is 1-3%.
Complications of pertussis in older infants and children are usually minimal,
and most patients make a gradual, but full, recovery with supportive care
and antibiotics. Minor complications during the illness include epistaxis,
nausea and vomiting, subconjunctival hemorrhages, and ulcers of the
frenulum.
Patients with certain comorbid conditions, however, have a higher risk of
morbidity and mortality and should be evaluated on an individual basis.
In addition, 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. [14]
Reported deaths due to pertussis in young infants have increased
substantially since the late 20th century. Between 2004 and 2008, out of a
total 111 pertussis-related deaths reported to the CDC, 92 (83%) were in
infants aged 3 months or less. [27, 28, 15]
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. [26]
Central nervous system (CNS) complications, such as seizures (1-2% of
infants) 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.
Failure to thrive is another possible complication of pertussis.
Leukocytosis, particularly with white blood cell (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.
Infants born prematurely and patients with underlying cardiac, pulmonary,
neuromuscular, or neurologic disease are at high risk for complications of
pertussis (eg, pneumonia, seizures, encephalopathy, death).
Older children, adolescents, and adults often have mild or atypical illness.
Approximately one half of adolescents with pertussis cough for 10 weeks or
longer. Complications among adolescents and adults include syncope,
sleep disturbance, incontinence, rib fractures, and pneumonia. Seizures
occur in 0.3-0.6% of adults.
Control measures should be implemented immediately when 1 or more
cases of pertussis are recognized in health care settings such as 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
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 US
Food and Drug Administration (FDA) and standard infection control
precautions.
For patient education information, see the Children's Health Center, as well
as Whooping Cough (Pertussis) and Immunization Schedule, Children.

PRESENTATION

History
Typically, the incubation period of pertussis ranges from 3-12 days.
Pertussis is a 6-week disease divided into catarrhal, paroxysmal, and
convalescent stages, each lasting from 1-2 weeks.
Older children, adolescents, and adults may not exhibit distinct stages.
Symptoms in these patients include uninterrupted coughing, feelings of
suffocation or strangulation, and headaches. Vaccinated adults usually
develop only prolonged bronchitis without a whoop, whereas unvaccinated
adults are more likely to have whooping and posttussive emesis.
Stage 1 - Catarrhal phase

The initial (catarrhal) phase is indistinguishable from common upper

respiratory infections. It includes nasal congestion, rhinorrhea, and
sneezing, variably accompanied by low-grade fever, tearing, and
conjunctival suffusion. Pertussis is most infectious when patients are in the
catarrhal phase, but pertussis may remain communicable for 3 or more
weeks after the onset of cough.
Stage 2 - Paroxysmal phase

Patients in the second (paroxysmal) phase present with paroxysms of

intense coughing lasting up to several minutes. In older infants and
toddlers, the paroxysms of coughing occasionally are followed by a loud
whoop as inspired air goes through a still partially closed airway. Infants
younger than 6 months do not have the characteristic whoop but may have
apneic episodes and are at risk for exhaustion. Posttussive vomiting and
turning red with coughing are common in affected children.
Stage 3 - Convalescent phase

Patients in the third (convalescent) stage have a chronic cough, which may
last for weeks.

Physical Examination
In patients with uncomplicated pertussis, physical examination findings
contribute little to the diagnosis. In all patients with pertussis, fever is
typically absent. Most patients do not have signs of lower respiratory tract
disease. Conjunctival hemorrhages and facial petechiae are common and
result from intense coughing. Dehydration is also common on presentation.
Hypoxia should be considered and assessed.
The classic inspiratory gasp or whoop develops primarily in children aged 6
months to 5 years. It is usually absent in patients younger than 6 months
and in most older vaccinated children and adults. However, it can often be
observed in unvaccinated adults, as can posttussive emesis.

Diagnostic Considerations
Illnesses that mimic clinical pertussis include the following:
 Adenoviral respiratory infection - Children present with fever, sore throat, and
conjunctivitis
 Mycoplasmal pneumonia - Patients with mycoplasmal infections have more
pronounced systemic symptoms, fever and headache may occur, and rales
may be appreciated on chest auscultation
 Chlamydial pneumonia - Young infants with chlamydial infections present with
staccato cough, purulent conjunctival discharge, tachypnea, rales, and
wheezing
 Respiratory syncytial virus infection - Patients present with predominantly lower
respiratory tract signs (eg, wheezing, rales)
Other conditions to consider in the differential diagnosis of pertussis include the
following:
 Common cold
 Influenza
 Cystic fibrosis
 Interstitial pneumonitis
 Bronchiolitis
 Croup (Laryngotracheobronchitis)
 Dehydration
 Febrile Seizures
 Fever
 Gastroenteritis
 Intussusception
 Tachycardia
 Aspiration pneumonia
 Bacterial pneumonia
 Viral pneumonia
  Tuberculosis
Differential Diagnoses
 Afebrile Pneumonia Syndrome
 Asthma
 Bronchiolitis
 Chlamydial Genitourinary Infections
 Chronic Obstructive Pulmonary Disease (COPD) and Emphysema in
Emergency Medicine
 Emergent Treatment of Gastroenteritis
 Encephalitis
 Pediatric Mycoplasma Infections
 Respiratory Syncytial Virus Infection
 Trachea Foreign Bodies

Approach Considerations
The criterion standard for diagnosis of pertussis is isolation of B pertussis in
culture. However, laboratory confirmation of pertussis is difficult and
delayed. Therefore, clinicians need to make the diagnosis of pertussis
presumptively in patients with a history of intense paroxysmal coughing
with or without whooping, color changes, posttussive vomiting, incomplete
or absent pertussis vaccination, and a finding of lymphocytosis on
laboratory examination.
A clinical case of pertussis is defined as one of the following:
 An acute coughing illness that lasts at least 14 days in a person with at
least one characteristic pertussis symptom (ie, paroxysmal cough,
posttussive vomiting, or inspiratory whoop)
 A cough that lasts at least 14 days in an outbreak setting
A confirmed case is defined as one of the following:
 Any cough illness in which B pertussis is isolated and cultured (see the
image below)
 A case consistent with the clinical case definition confirmed by
polymerase chain reaction (PCR) assay findings or epidemiologic
linkage to a laboratory-confirmed case
 A photomicrograph of
the bacterium Bordetella pertussis, using Gram stain technique.

Imaging studies typically add little to the diagnosis of pertussis but should
be obtained when clinically indicated, based on examination or if the patient
requires supplemental oxygen.
Serologic antibody titer testing is available, but often needs to be compared
with results 1-2 weeks later and thus is not commonly helpful. The Centers
for Disease Control and Prevention (CDC) also performs characterization
of B pertussis isolates by serologic and molecular subtyping methods for
outbreak support and other public health concerns. Laboratory testing is
provided only upon prior communication with the Pertussis and Diphtheria
Laboratory, indicating the reason for this service.
The use of direct fluorescent assay (DFA) of nasopharyngeal secretions is
not recommended by the CDC; although the results can be available within
minutes, the test has low sensitivity and specificity.
Chest radiography

Chest radiography may reveal perihilar infiltrates or edema with variable

degrees of atelectasis. Consolidation is indicative of secondary bacterial
infection or, rarely, pertussis pneumonia.
Occasionally, pneumothorax, pneumomediastinum, or air in the soft tissues
may be seen.

Blood Work
Leukocytosis (15,000-50,000/µL) with absolute lymphocytosis occurs
during the late catarrhal and paroxysmal phases. It is a nonspecific finding
but correlates with the severity of the disease. One study showed that
among infants suspected of having pertussis, an absolute leukocyte count
lower than 9400/μL excluded almost all infants who had a negative
pertussis test finding. [29] In adults, especially those who have been
vaccinated, lymphocytosis is rare.
In infants aged 90 days or younger, early serial monitoring of white blood
cell (WBC) counts is crucial for identifying risk and determining the
prognosis of infants with pertussis. A retrospective study of 31 infants with
pertussis found that WBC counts higher than 30,000/μL (within a mean of
5.1 days after cough onset), rapid heart rates, and hyperventilation were
indicators of severe B pertussis infection. [30,31]
In this study, WBC counts in infants with severe disease tended to elevate
more rapidly than those in infants with less severe disease. [30, 31] Moreover,
WBC counts reached higher peaks in patients with severe pertussis than in
those with less severe pertussis (mean, 74,200/μL vs 26,900/μL; median,
74,100/μL vs 24,200/μL).

Cultures
The results of blood culture are uniformly negative because B
pertussis grows solely in the respiratory epithelium. The culture specimen
should be obtained by using deep nasopharyngeal aspiration or by holding
a flexible swab (Dacron or calcium alginate) in the patient's posterior
nasopharynx for 15-30 seconds or until a cough is produced.
The sample special media (preferred media include Regan-Lowe or Bordet-
Gengou agar and modified Stainer-Scholte media) should be promptly
inoculated. B pertussis usually grows after 3-4 days; however, culture
findings cannot be considered negative for pertussis until after 10 days.
Recovery rates are highest during the catarrhal or early paroxysmal phase
and are low after the fourth week of illness.
See the following pertussis guideline pages from the CDC:
 Laboratory Information
 Diagnosis Confirmation
 Best Practices for Health Care Professionals on the use of Polymerase
Chain Reaction (PCR) for Diagnosing Pertussis
Culture findings may be negative in patients who were previously
immunized, have received antimicrobial therapy, or have been coughing for
more than 3 weeks. A negative culture finding does not exclude the
diagnosis of pertussis.

PCR Assay and ELISA

PCR assays and antigen detection are increasingly used to assist in
diagnosing pertussis. Advantages include greater sensitivity, more rapidly
available results, and use later in the disease course or after antimicrobial
therapy because the tests do not rely on the isolation of viable
organisms. [32] Their use is limited by lack of standardization and incomplete
understanding of the correlation between test results and the course of the
illness.
A PCR assay may reveal 10 organisms per swab sample, and its sensitivity
may be greater than that of culturing.
However, false-positive results have been a problem, with some reports of
more than 50%. Although this or a positive culture is the case definition for
reporting pertussis to the CDC or the World Health Organization (WHO),
some are now recommending confirmation with enzyme-linked
immunosorbent assay (ELISA) before declaring an epidemic. (Many now
consider serologic testing with ELISA to be the criterion standard.)
The CDC recommends a combination of culture and PCR assay if a patient
has a cough lasting longer than 3 weeks.

Approach Considerations
Supportive therapy is the mainstay of treatment in patients with active
pertussis infection. [23] The goals of therapy include limiting the number of
paroxysms, observing the severity of cough, providing assistance when
necessary, and maximizing nutrition, rest, and recovery. Oxygenation,
breathing treatments, and mechanical ventilation should be provided as
necessary. Infants should be carefully observed for apnea, cyanosis, or
hypoxia.
Inpatient care is required for patients with pertussis who have intractable
nausea and vomiting, failure to thrive, seizures, or encephalopathy or for
patients with sustained hypoxemia during coughing paroxysms who require
supplemental oxygen.
Hospitalization should be strongly considered for patients at risk for severe
disease and complications, including infants younger than 3 months;
infants aged 3-6 months, unless observed paroxysms are not severe;
premature young infants; and infants or children with underlying pulmonary,
cardiac, or neuromuscular disease.
Patients with pneumonia, apneic or cyanotic spells, hypoxia, or moderate to
severe dehydration should also be considered for admission. Patients who
are severely ill may require treatment in an intensive care unit (ICU).
For the hospitalized patient, in addition to standard precautions, droplet
precautions are recommended for 5 days after initiation of effective therapy
or until 3 weeks after the onset of paroxysms if appropriate antimicrobial
therapy is not given.
Continuously monitor the heart rate, respiratory rate, and oxygen saturation
of hospitalized patients, especially in relation to coughing paroxysms.
Coughing, feeding, vomiting, and weight changes should be recorded. Pay
attention to the young infant's hydration and nutritional status.
Diet and activity

No special diet is indicated, although a clinically age-appropriate diet

should be maintained. Infants who cannot tolerate oral feedings may
require intravenous fluids.
Activity for patients with pertussis should be guided by clinical course. In
general, patients engage in activity as tolerated.
Consultations

Consultation with subspecialists is usually not indicated; however, if the

diagnosis is unclear or the clinical course warrants, infectious disease
specialists or other subspecialists should be consulted.
Transfer

Transfer of patients is not usually indicated unless inpatient therapy and

monitoring are warranted and facilities for these 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.
Monitoring

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

Pharmacologic Therapy
Although antimicrobial agents initiated during the paroxysmal stage do not
affect the duration and severity of illness, they can hasten the eradication
of Bpertussis in the respiratory tract and help to prevent spread. Antibiotics
may also prevent or alleviate secondary bacterial infection.
For patients of all ages azithromycin is the preferred agent.
Erythromycin and clarithromycin are not recommended in infants younger
than 1 month, because their use has been associated with increased risk of
infantile hypertrophic pyloric stenosis (IHPS). Azithromycin is the
recommended agent for the youngest patients, although it also carries
some risk of IHPS. Patients who are aged 2 months or older with
hypersensitivity to macrolides may be treated with trimethoprim-
sulfamethoxazole.
Prophylaxis

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:
 Azithromycin (5 d)
 Erythromycin (14 d)
 Alternative regimen - Clarithromycin 7.5 mg/kg twice daily for 14 days
(the effectiveness of clarithromycin has not been proven but is
inferred)
Immunization
Prevention through immunization remains the best defense in the fight
against pertussis. However, because nearly all of the fatal cases of
pertussis occur in infants who are too young to have been immunized,
novel strategies must be explored to protect these patients.
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. A study from the Netherlands concluded that 35-55% of
pertussis cases in infants could be prevented if immunity to pertussis in
parents were maintained or boosted. [33]
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. [34, 35] 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 for patients aged 11-64 years (Adacel;
Sanofi Pasteur, Toronto, Canada). Tdap has replaced tetanus in the
childhood and adult immunization schedules. It has been shown to be
effective in outbreaks in the short term. Long-term effectiveness studies are
ongoing.
Whole-cell vaccination

This vaccine, used from the 1940s until the mid-1990s in the United States
and from the 1940s until the 1980s in Europe, consisted of a whole cell with
endotoxin given in 4 doses. About 80% of recipients acquired effective
protection with this regimen. Two doses provided some immunity, whereas
1 dose provided little protection.
It was found that about 50% of patients who received the vaccine had a
local reaction to it, 1 patient in 1750 had a seizure without fever, and 10.5
patients per million developed encephalitis; permanent brain damage was
rare. Concern about CNS adverse effects is a major reason why many
individuals chose not to be vaccinated.
Acellular vaccination

Vaccination is now recommended with acellular pertussis vaccine plus

diphtheria and tetanus toxoids (DTaP) at the ages of 2, 4, 6, and 15-18
months and at age 4-6 years. A booster with Tdap (DTaP is not
recommended for children aged 7 years or older) is recommended instead
of 1 diphtheria-tetanus toxoid (Td) booster from age 19 years and up.
Ideally, Tdap is recommended before pregnancy, but it may be given
during pregnancy after 20 weeks’ gestation. [36] Additionally, the CDC
recommends that all adults receive 1 dose of Tdap in order to decrease
pertussis transmission in children.
After immunization, fever is reported in 3-5% of patients, persistent crying
in 12 patients per 100,000, febrile seizures in 5 patients per 100,000,
afebrile seizure in 2 patients per 100,000, and hyporesponsive episodes in
5 patients per 100,000. Severe neurologic sequelae have not been
reported. This is about the same as it is for Td alone.
A study found that the pertussis vaccine did not increase the risk of
adverse birth outcomes in an observational study of 123,494 women who
gave birth to a live singleton infant, including 26,229 who received the
acellular pertussis vaccine (Tdap) during pregnancy. [37, 38] Crude estimates
for preterm delivery were 6.3% among vaccinated women and 7.8% among
unvaccinated women (adjusted risk ratio [RR] 1.03). Estimates for small for
gestational age birth were 8.4% in vaccinated women and 8.3% in
unvaccinated woman (adjusted RR, 1.00). Women who received Tdap
before 20 weeks were not at increased risk for hypertensive disorder of
pregnancy (adjusted RR, 1.09). The study did find a small but statistically
significant increased risk of chorioamnionitis with Tdap vaccination during
pregnancy. Chorioamnionitis was diagnosed in 6.1% of vaccinated women
and 5.5% of unvaccinated women, for an adjusted risk ratio of 1.19. [37, 38]
A study by Kent et al found that maternal vaccination administered early in
the third trimester may provide protection against pertussis and other
pathogens for infants born prematurely. In the study, mothers of 31 (19%)
of 160 premature infants received combined tetanus, diphtheria, 5-
component acellular pertussis, inactivated polio vaccine in pregnancy. The
study reported that compared with infants of unvaccinated mothers, those
born to vaccinated mothers had significantly higher antibody concentrations
at 2 months for all measured vaccine antigens. [39]
For the latest childhood and adolescent immunization recommendations,
see the CDC immunization schedules. [35, 40]

Medication Summary
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 immunoglobulin is an investigational product that may be
effective in decreasing paroxysms of cough, although it 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.

Antibiotics, Other
Class Summary

The Committee on Infectious Diseases (COID) 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. [41] This
is regardless of the age or immunization status of contacts.
A 14-day course of oral erythromycin is the antimicrobial therapy of choice
for patients with pertussis and for close contacts. Typical dosing schedule
is 40-50 mg/kg/day (not to exceed 2 g/day) 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.
Erythromycin (E.E.S., EryPed, Ery-Tab, Erythrocin)

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Erythromycin inhibits bacterial growth, possibly by blocking the dissociation
of peptidyl transfer ribonucleic acid (tRNA) from ribosomes, causing RNA-
dependent protein synthesis to arrest.
Erythromycin estolate is the antibiotic of choice to prevent interpersonal
transfer, because of enhanced absorption, particularly in young infants. (Its
effectiveness in prophylaxis for exposed and susceptible persons has not
been determined.)
Erythromycin is recommended for household and close contacts (50
mg/kg/day PO qid for 14 days). It is effective in reducing the course and
symptoms of pertussis if it is started within the first 10-14 days, but its
efficacy has not proven beyond this period.
Azithromycin (Zithromax, Zmax)

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Azithromycin inhibits bacterial growth, possibly by blocking the dissociation
of peptidyl tRNA from ribosomes, causing RNA-dependent protein
synthesis to arrest. It has been shown in several small studies to be
effective against pertussis.
Clarithromycin (Biaxin)

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Clarithromycin inhibits bacterial growth, possibly by blocking the
dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent
protein synthesis to arrest. It has been shown in small studies to be
effective against pertussis.
Trimethoprim-sulfamethoxazole (Bactrim, Bactrim DS, Septra DS)

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This agent inhibits bacterial growth by inhibiting the synthesis of
dihydrofolic acid. It can be used as an alternative drug, although its efficacy
against pertussis has not