Pertussis Treatment
Azithromycin is the recommended first-line treatment for pertussis due to its once-daily dosing, excellent tolerability, and shorter treatment duration compared to other antibiotics. 1
Recommended Antibiotic Regimens
First-Line Treatment: Azithromycin
- Adults: 500 mg on day 1, then 250 mg daily for 4 days (5 days total) 1
- Children: 10 mg/kg on day 1, then 5 mg/kg daily for 4 days (5 days total) 1, 2
Alternative Options:
Erythromycin:
Clarithromycin:
- Children: 7.5 mg/kg twice daily for 7 days 4
Trimethoprim-sulfamethoxazole:
- For patients who cannot tolerate macrolides
- Contraindicated in infants under 2 months, pregnant women, and nursing mothers 1
Treatment Timing and Effectiveness
Early treatment within the first few weeks of illness is crucial as it will:
- Diminish coughing paroxysms
- Prevent disease spread 1
Treatment initiated after the paroxysmal phase has limited effect on the clinical course but remains important for reducing transmission.
Infection Control Measures
- Patients should be isolated for 5 days from the start of antimicrobial therapy 1
- Healthcare workers should be excluded from work until 5 days after starting appropriate therapy 1
- Droplet precautions should be employed for hospitalized patients 1
- Patients should be isolated at home and away from work or school for 5 days after starting antibiotic therapy 1
Comparative Efficacy and Tolerability
Azithromycin is preferred over erythromycin because:
- Equal bacteriologic eradication rates (100% for azithromycin vs. 96-100% for erythromycin) 2, 4
- Significantly fewer gastrointestinal adverse events (18.8% vs. 41.2%) 2
- Better compliance (90% vs. 55% taking all prescribed doses) 2
- Shorter treatment duration (5 days vs. 14 days) 1, 2
What NOT to Offer
The following should not be offered to patients with pertussis as there is no evidence of benefit:
- Long-acting β-agonists
- Antihistamines
- Corticosteroids
- Pertussis immunoglobulin 1
Special Considerations
Severe Cases
- Monitor for hyperleukocytosis, which is associated with severe disease and mortality risk 5
- In severe cases with hyperleukocytosis, plasma exchange may be considered 5
Side Effects and Contraindications
- Erythromycin: Associated with gastrointestinal side effects and infantile hypertrophic pyloric stenosis in infants under 1 month 1
- Trimethoprim-sulfamethoxazole: Higher risk of adverse effects including rash and blood dyscrasias 1
Complications to Monitor
Complications from severe coughing can include:
- Pneumothorax
- Rib fracture
- Epistaxis
- Subconjunctival hemorrhage
- Subdural hematoma
- Hernia
- Rectal prolapse
- Urinary incontinence
- Loss of consciousness/cough syncope 1
Post-Exposure Prophylaxis
The same antimicrobial regimens used for treatment are recommended for post-exposure prophylaxis for all close contacts, regardless of vaccination status, and are most effective when initiated within 2 weeks of exposure 1.