What is the recommended treatment for pertussis?

Treatment for Pertussis

Azithromycin is the recommended first-line treatment for pertussis due to its once-daily dosing, excellent tolerability, shorter treatment duration, and higher compliance rates 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)
• Children: 10 mg/kg on day 1, then 5 mg/kg daily for 4 days (5 days total) 1

Alternative Treatments

1. Erythromycin:

   • Adults: 500 mg every 12 hours or 250 mg four times daily for 14 days
   • Children: 40-50 mg/kg/day in divided doses for 14 days 1, 2
   • Note: Associated with more gastrointestinal side effects (nausea, vomiting, diarrhea) and lower compliance rates (57% vs 93% for azithromycin) 3

2. Trimethoprim-sulfamethoxazole:

   • Important contraindications: infants under 2 months, pregnant women, and nursing mothers 1
   • Higher risk of adverse effects including rash and blood dyscrasias

Timing and Effectiveness of Treatment

• Early treatment within the first few weeks of illness is crucial to:

  • Diminish coughing paroxysms
  • Prevent disease spread 1
  • Eliminate Bordetella pertussis from the nasopharynx, rendering patients non-infectious 2

• Treatment initiated later in the disease course (paroxysmal or convalescent phases) has limited effect on established symptoms such as paroxysms, emesis, or apnea 4

Infection Control Measures

• Isolation: Patients should be isolated for 5 days from the start of antimicrobial therapy 1
• Healthcare settings: Employ droplet precautions for hospitalized patients 1
• Work/School: Patients should stay home from work or school for 5 days after starting antibiotic therapy 1
• Healthcare workers: Should be excluded from work until 5 days after starting appropriate therapy 1

What NOT to Offer

The following treatments show no evidence of benefit for pertussis and should not be prescribed 1:

• Long-acting β-agonists
• Antihistamines
• Corticosteroids
• Pertussis immunoglobulin

Post-Exposure Prophylaxis

• Recommended for all close contacts, regardless of vaccination status
• Same antimicrobial regimens as for treatment
• Most effective when initiated within 2 weeks of exposure 1

Special Considerations

• Complications: Severe coughing can lead to pneumothorax, rib fracture, epistaxis, subconjunctival hemorrhage, subdural hematoma, hernia, rectal prolapse, urinary incontinence, and loss of consciousness/cough syncope 1

• Medication-specific concerns:

  • Erythromycin inhibits cytochrome P450, leading to potentially serious drug interactions 1
  • Erythromycin is associated with infantile hypertrophic pyloric stenosis in infants under 1 month 1

Prevention

• Vaccination remains the most effective prevention strategy
• Neither vaccination nor natural disease confers lifelong immunity (immunity wanes after 5-10 years) 1
• Pregnant women should receive Tdap between 27-36 weeks' gestation with each pregnancy 1, 4