From the Guidelines
The best treatment for pertussis is antibiotics, specifically macrolides such as azithromycin, clarithromycin, or erythromycin, with azithromycin being the preferred choice for most patients. For most patients, azithromycin is preferred, given as a 5-day course: 10 mg/kg (maximum 500 mg) on day 1, followed by 5 mg/kg (maximum 250 mg) daily for days 2-5 1. Alternatively, clarithromycin can be given at 15 mg/kg/day divided into two doses (maximum 1g/day) for 7 days, or erythromycin at 40-50 mg/kg/day divided into four doses (maximum 2g/day) for 14 days.
Key Considerations
- Treatment is most effective when started within the first 1-2 weeks of symptom onset, as it can reduce symptom severity and duration, though it may have limited effect on the characteristic cough once established 1.
- Antibiotics also importantly reduce the period of contagiousness to about 5 days after starting treatment.
- Supportive care is essential, including:
- Maintaining hydration
- Managing secretions
- Monitoring for respiratory distress
- Avoiding irritants that trigger coughing
- For severe cases, especially in infants, hospitalization may be necessary for respiratory support and monitoring 1.
- Prevention through vaccination remains the most effective strategy against pertussis, with vaccination coverage varying across age groups in the United States 1.
Special Considerations
- For infants aged <1 month, azithromycin is the preferred macrolide for postexposure prophylaxis and treatment, due to the risk of infantile hypertrophic pyloric stenosis associated with erythromycin 1.
- The choice of antimicrobial agent should take into account effectiveness, safety, tolerability, ease of adherence to the regimen prescribed, and cost 1.
From the Research
Treatment Options for Pertussis
- Erythromycin is accepted as the treatment of choice for pertussis, reducing the severity and duration of the disease 2
- A 14-day course of erythromycin is recommended, although a 7-day course may have similar efficacy in terms of eradication and prevention of relapse 2
- Alternatives to erythromycin include clarithromycin, azithromycin, and trimethoprim-sulfamethoxazole 2, 3, 4
- Fluoroquinolones have good in vitro activity against both B. pertussis and B. parapertussis, but there are no supporting clinical data for their use in treating pertussis 2
Comparison of Antibiotic Regimens
- A 7-day regimen of clarithromycin and a 14-day course of erythromycin were found to be equally effective for treating pertussis, with clarithromycin being better tolerated 3
- Short-term treatment with azithromycin or clarithromycin was found to be equal or superior to the standard long-term erythromycin regimen for pertussis 4
- A systematic review found that short-term antibiotics (azithromycin for three days, clarithromycin for seven days, or erythromycin estolate for seven days) were equally effective with long-term antibiotic treatment (erythromycin estolate or erythromycin for 14 days) in microbiological eradication of B. pertussis 5
Recommendations for Treatment
- The American Family Physician recommends a 14-day erythromycin regimen as the treatment of choice, but notes that shorter-course macrolide antibiotics (e.g., azithromycin, clarithromycin) may be as effective with fewer adverse effects and better adherence to therapy 6
- The Cochrane review recommends three days of azithromycin or seven days of clarithromycin as the best regimens for treating pertussis, considering microbiological clearance and side effects 5