How is Pertussis (whooping cough) managed and treated?

Management and Treatment of Pertussis (Whooping Cough)

Macrolide antibiotics are the first-line treatment for confirmed or suspected pertussis cases, and patients should be isolated for 5 days from the start of treatment to prevent disease spread. 1

Diagnosis

Early diagnosis is crucial for effective management of pertussis. Consider the diagnosis when:

• Cough lasts ≥ 2 weeks without another apparent cause
• Cough is accompanied by paroxysms of coughing, post-tussive vomiting, and/or inspiratory whooping sound 1

Diagnostic Testing

1. Nasopharyngeal culture: The gold standard for definitive diagnosis 1

   • Collect nasopharyngeal aspirate or Dacron swab
   • Should be performed early in the course of illness

2. Serology:

   • Paired acute and convalescent sera showing a fourfold increase in IgG or IgA antibodies to pertussis toxin (PT) or filamentous hemagglutinin (FHA) 1
   • Less reliable than culture but useful when culture is not available

3. PCR testing:

   • Available but not universally recommended due to lack of standardized techniques 1
   • Has replaced culture as the preferred confirmatory test in many settings 2

Treatment Algorithm

1. Antimicrobial Therapy

• First-line treatment: Macrolide antibiotics 1, 3, 2

  • Azithromycin (preferred due to better side-effect profile and compliance)
  • Clarithromycin
  • Erythromycin (40-50 mg/kg/d in children; 1-2 g/day in adults for 2 weeks)

• Alternative for macrolide allergy: Trimethoprim/sulfamethoxazole 1, 3

• Timing considerations:

  • Most effective when started early (catarrhal phase, first 2 weeks)
  • May have limited benefit in paroxysmal phase
  • Treatment beyond this period may be offered but response is unlikely 1

2. Infection Control

• Isolate patients for 5 days from the start of antibiotic treatment 1
• Keep patients away from work or school during isolation period

3. Prophylaxis

• Provide antibiotic prophylaxis to:
  • Household contacts
  • High-risk individuals exposed to pertussis (infants, immunocompromised persons, pregnant women in third trimester) 2
  • Use same antibiotics as for treatment

4. Supportive Care

• Maintain hydration and nutrition
• Monitor respiratory status, especially in infants and young children
• Hospitalize high-risk patients (infants <6 months, severe cases)

5. Management of Complications

• For severe cases with hyperleukocytosis:
  • Consider plasma exchange in specialized centers 4
  • Provide respiratory support as needed

Important Considerations

What NOT to Use

• Ineffective treatments: Long-acting β-agonists, antihistamines, corticosteroids, and pertussis immunoglobulin have shown no significant benefit in controlling coughing paroxysms 1

Special Populations

• Infants: Higher risk for severe complications (apnea, pneumonia, seizures, death) 3

  • Require closer monitoring and often hospitalization
  • May need respiratory support

• Adolescents and adults: Complications typically related to chronic cough 3

  • May have atypical presentation with prolonged cough but without classic whoop

Prevention

• Vaccination:
  • Children: Complete DTaP primary series (5 doses before age 7) 1, 3
  • Adolescents: Single dose of Tdap booster between 11-18 years 3, 2
  • Adults: At least one dose of Tdap 2
  • Pregnant women: Tdap between 27-36 weeks' gestation with each pregnancy 2

Common Pitfalls to Avoid

• Delaying antibiotic treatment while waiting for diagnostic confirmation
• Failing to isolate patients during the infectious period
• Not providing prophylaxis to close contacts
• Attempting to treat with ineffective therapies (corticosteroids, antihistamines)
• Overlooking the diagnosis in adolescents and adults who may present atypically

Prognosis

• Early treatment within the first few weeks will diminish coughing paroxysms and prevent disease spread 1
• Antibiotics do not significantly shorten the course of illness once established 2
• Recovery is typically complete, though the cough may persist for weeks to months