Pertussis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]; Rim Halaby, M.D. [3]
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Overview
Early treatment of pertussis is very important. The earlier a person, especially an infant, starts treatment the better. A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset. The recommended antimicrobial agents for treatment or chemoprophylaxis of pertussis are azithromycin, clarithromycin and erythromycin. Trimethoprim-sulfamethoxasole can also be used. Consider using an alternative drug to azithromycin in those who have known cardiovascular disease.[1]
Medical Therapy
- Early treatment of pertussis is very important. The earlier a person, especially an infant, starts treatment the better. If treatment for pertussis is started early in the course of illness, during the first 1 to 2 weeks before coughing paroxysms occur, symptoms may be lessened. Clinicians should strongly consider treating prior to test results if clinical history is strongly suggestive or patient is at risk for severe or complicated disease (e.g. infants). If the patient is diagnosed late, antibiotics will not alter the course of the illness and, even without antibiotics, the patient should no longer be spreading pertussis.[1]
- Persons with pertussis are infectious from the beginning of the catarrhal stage (runny nose, sneezing, low-grade fever, symptoms of the common cold) through the third week after the onset of paroxysms (multiple, rapid coughs) or until 5 days after the start of effective antimicrobial treatment.[1]
- A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset. The recommended antimicrobial agents for treatment or chemoprophylaxis of pertussis are azithromycin, clarithromycin and erythromycin. Trimethoprim-sulfamethoxasole can also be used.[1]
- The choice of antimicrobial should be made after consideration of the:[1]
- Potential for adverse events and drug interactions
- Tolerability
- Ease of adherence to the regimen prescribed
- Cost
- On March 12, 2013, the Food and Drug Administration (FDA) issued a warning that azithromycin can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm in some patients. Azithromycin remains one of the recommended drugs for treatment and chemoprophylaxis of pertussis, but consider using an alternative drug in those who have known cardiovascular disease, including:[1]
- Patients with known prolongation of the QT interval, a history of torsades de pointes, congenital long QT syndrome, bradyarrhythmias, or uncompensated heart failure
- Patients on drugs known to prolong the QT interval
- Patients with ongoing proarrhythmic conditions such as uncorrected hypokalemia or hypomagnesemia, clinically significant bradycardia, and in patients receiving Class IA (quinidine, procainamide) or Class III (dofetilide, amiodarone, sotalol) antiarrhythmic agents.
- Elderly patients and patients with cardiac disease may be more susceptible to the effects of arrhythmogenic drugs on the QT interval.
Infants
Age ≥1 Month
- Erythromycin, clarithromycin, and azithromycin are preferred for the treatment of pertussis in persons ≥1 month of age.[1]
- For persons ≥2 months of age, an alternative to macrolides is trimethoprim-sulfamethoxazole.[1]
Age <1 Month
- For infants <1 month of age, azithromycin is preferred for post exposure prophylaxis and treatment because azithromycin has not been associated with infantile hypertrophic pyloric stenosis (IHPS), whereas erythromycin has.[1]
- For infants <1 month of age, the risk of developing severe pertussis and life-threatening complications outweighs the potential risk of IHPS that has been associated with macrolide use.[1]
- Infants <1 month of age who receive a macrolide should be monitored for the development of IHPS and for other serious adverse events.[1]