What is the recommended treatment for whooping cough (pertussis)?

Treatment of Whooping Cough (Pertussis)

Azithromycin is the preferred first-line treatment for pertussis due to its effectiveness in bacterial eradication, better side effect profile, and improved compliance compared to erythromycin. 1, 2

First-Line Treatment Options

Azithromycin (Preferred)

• Infants <6 months: 10 mg/kg per day for 5 days 1
• Children >6 months: 10 mg/kg (maximum: 500 mg) on day 1, followed by 5 mg/kg per day (maximum: 250 mg) on days 2-5 1
• Adults: 500 mg on day 1, followed by 250 mg per day on days 2-5 1

Alternative Macrolides

• Clarithromycin:
  • Children: 10 mg/kg per day, divided into two doses for 7 days 3
  • Adults: Standard adult dosing for 7 days 1

Second-Line Options

• Erythromycin (if other macrolides unavailable):

  • Adults: 500 mg four times daily for 14 days 4
  • Children: 40-50 mg/kg/day in four divided doses for 14 days 4

• Trimethoprim/sulfamethoxazole:

  • For patients with macrolide intolerance or allergy 5, 6

Treatment Considerations

Timing of Treatment

• Treatment is most effective when initiated during the catarrhal phase (first 1-2 weeks) 5, 1
• Early treatment can:
  • Rapidly clear B. pertussis from the nasopharynx
  • Decrease coughing paroxysms
  • Reduce complications
  • Limit transmission to others 5

Duration of Isolation

• Patients should be isolated at home and away from work or school for 5 days after starting antibiotic therapy 5, 1

Efficacy Considerations

• While antibiotics effectively eliminate B. pertussis from the nasopharynx, they have limited effect on the clinical course once the paroxysmal stage has begun 7, 6
• Treatment during the paroxysmal phase has limited benefit for symptom reduction but remains important for preventing transmission 5

Management of Complications

Monitoring for Complications

• Infants: Monitor for apnea, pneumonia, seizures, cyanosis during coughing episodes 1
• All ages: Watch for complications from severe coughing including:
  • Pneumothorax (up to 5%)
  • Rib fracture (up to 4%)
  • Subdural hematoma
  • Loss of consciousness/cough syncope (3-6%)
  • Weight loss and sleep disturbance 1

Supportive Care

• Ensure adequate hydration and nutrition
• Consider hospitalization for severe symptoms or complications, especially in infants 1

Adjunctive Therapies

• Long-acting β-agonists, antihistamines, corticosteroids, and pertussis immunoglobulin have not shown significant benefit in controlling coughing paroxysms 5

Common Pitfalls to Avoid

1. Delayed treatment: Don't wait for laboratory confirmation before initiating therapy in suspected cases 5, 1
2. Inadequate duration: Complete the full course of antibiotics even if symptoms improve 1
3. Overlooking contacts: Consider prophylaxis for close contacts regardless of vaccination status 1
4. Macrolide interactions: Be aware of potential drug interactions, particularly with medications metabolized by cytochrome P450 enzymes 1
5. Monitoring infants: Watch for signs of infantile hypertrophic pyloric stenosis in infants receiving macrolides 1

Prevention

• Vaccination remains the most effective prevention strategy 1
• Prophylaxis for exposed contacts can help prevent secondary cases and reduce transmission 1
• The same antibiotics and dosing used for treatment are recommended for prophylaxis 1