Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Pertussis
An acute, highly communicable respiratory illness commonly known as whooping cough. It is a vaccine-preventable disease, the classic manifestation of which is a “whoop” caused by a sudden massive inspiration following episodes of severe repetitive coughing.
I. Etiology:
Bordetella pertussis, a gram-negative, pleomorphic bacillus
II. Incidence
A. Pertussis is becoming increasingly important in the differential diagnosis of cough.
B. Incidence increased from a low of 1,060 cases in 1976 to more than 25,000 reported cases in 2004.
C. More than a third of cases occurred in adolescents 11–18 years of age.
D. Protection after the last dose of DPT decreases within 5–10 years and is generally absent 12 years after the last dose.
E. Statistically, it occurs worldwide with about 1 million deaths in children every year
F. It is the most commonly seen vaccine-preventable disease (except for varicella). If allowances are made for underreporting and misdiagnosis, the actual rate would be dramatically higher.
G. Occurs endemically with 3to 5-year cycles of increased incidence
III. Incubation period:
7 to 10 days following exposure, with a range of 6 to 21 days.
IV. Communicability
A. Transmission occurs from person to person by respiratory droplet infection and is highly communicable from the onset of the catarrhal stage.
B. If not on antibiotics, transmission occurs from 2 weeks before, until 3 weeks after cough onset.
C. If on antibiotics, communicable from 2 weeks before onset of cough through fifth day of treatment.
V. Subjective data
A. History of upper respiratory infection that becomes progressively worse
B. Cough that becomes increasingly persistent over a period of 1 to 2 weeks
C. Generally afebrile
D. Classically presents in three stages
1. Phase I, catarrhal stage: 2-week duration
a. Cough
b. Coryza
2. Phase II, paroxysmal stage: 2to 4-week duration
a. Episodic, sudden coughing
b. Whooping with cough (pathognomonic)
c. Vomiting after cough
3. Phase III, convalescent stage: Lasts months
E. Paroxysms may be precipitated by eating, drinking, or activity.
F. Paroxysms may occur 20 or more times a day.
G. Whoop and paroxysms may be mild or absent in children and young adults who have been immunized.
H. In infants, apnea is common, and whoop is often absent.
I. History of exposure to person with a chronic paroxysmal cough
VI. Objective data
A. Generally no significant physical findings to confirm diagnosis
B. Cough
1. Episodic, paroxysmal
2. Whoop may be heard.
C. Subconjunctival hemorrhages
D. Petechiae
E. Check for signs of secondary infection
1. Ears
2. Lungs
F. Hernia (inguinal or umbilical)
G. Laboratory tests
1. Children younger than 11 years
a. Nasopharyngeal culture for B. pertussis. (Use alginate swab, leave in place for 20 seconds, and inoculate special media.)
b. Most sensitive during catarrhal stage and during the first 14 days after onset of cough
c. In Massachusetts, send to State Laboratory Institute.
2. Children older than 11 years
a. Nasopharyngeal culture during catarrhal phase: 14 days or less of illness
b. Serology for IgG antibody to B. pertussis during paroxysmal stage after 14 days of illness
(1) Very specific
(2) Sensitivity increases with duration of cough.
3. Note: Serology is not interpretable in children younger than 11 years because of antibody levels persisting following immunization. If the new immunization guidelines have been followed and child age 11 or older has received a Tdap vaccination within the past 3 years, serology will not be interpretable as well.
VII. Diagnosis
A. If a whoop is present, the diagnosis is easily considered and confirmed by nasopharyngeal culture or serology.
B. Because the predominance of cases are atypical or modified by immunization, pertussis should be a diagnostic consideration in children or adolescents with a persistent cough or a prolonged paroxysmal cough and/or post-tussive emesis.
VIII. Plan
A. Preferred treatment—Erythromycin
1. Child: Erythromycin, 40 to 50 mg/kg/d in 4 divided doses for 14 days (> 20 kg, 250 qid). Maximum 2 g/d
2. Adult: Erythromycin, 500 mg qid for 14 days
B. Alternative treatment—Trimethoprim/Sulfamethaxole; do not use for infants 2 months of age or pregnant women
1. Child: Trimethoprim (TMP)/sulfamethoxazole (SMX), 8 mg TMP and 40 mg SMX/kg/d in 2 divided doses for 14 days (10 kg, 5 mL every 12 hours; > 40 kg, one DS tablet every 12 hours); maximum dose 320 mg TMP and 1,600 mg SMX/d
2. Adult: TMP/SMX, 160 mg TMP and 800 mg SMX/d in 2 divided doses for 14 days (one DS tablet every 12 hours)
C. Alternate treatment for those unable to tolerate erythromycin: Do not use for children less than 6 months, or pregnant women
1. Biaxin
a. Child: 15–20 mg/kg/d in 2 divided doses for 7 days (maximum dose 1 g/d)
b. Adult: 500 bid for 7 days
2. Zithromax
a. Child: 10–12 mg/kg/d, one dose/d for 5 days (maximum dose 600 mg)
b. Adult: 500 mg/d for 5 days
D. Prophylaxis guidelines: Broad-based prophylaxis is no longer routinely recommended.
1. Treat all household, close, and high-risk contacts regardless of age, history of disease, or immunization status. Treat the following presumptively after diagnostic specimens are obtained.
a. Close Contacts
(1) Direct contact
Explosive cough or sneeze in face, sharing food or eating utensils, kissing, sharing lip gloss/cigarettes, performing medical or dental exam
(2) Face-to-face contact
Have had face-to-face contact, regardless of duration, with a case that is symptomatic and infectious
(3) Household contact
Includes persons who are living in home at time of disease and other friends, relatives, caregivers who visit often, and intimate contacts.
b. High-risk contacts
(1) Infants less than 1 year
(2) Immunocompromised individuals
(3) Individuals with chronic lung disease such as asthma
(4) Individuals with neuromuscular disorders that prevent or reduce ability to clear secretions
(5) Unimmunized or under immunized children
c. Contacts who could transmit pertussis to those at high-risk: For example, household contacts, health care workers, child care workers with infants
d. Unimmunized or underimmunized children
2. Recommendation for prophylaxis is identical to treatment.
3. If complete course is not taken, the entire course must be repeated.
4. Entire classrooms are no longer routinely prophylaxed when there is only one confirmed case.
E. Report to local Board of Health and state Department of Public Health.
F. Close contacts under 7 years of age who are unimmunized or have received less than five doses of DTP/DTaP should, in addition to antibiotic prophylaxis, have pertussis immunization according to following guidelines:
1. Give dose 1 at about 6 weeks of age; doses 1, 2, and 3 must be separated by at least 4 weeks.
2. Children who have received their third dose of DTP/DTaP more than 6 months prior to exposure should receive a fourth dose.
3. Children who have received four doses of DTP/DTaP should have a booster unless given within the last three years.
IX. Education
A. Pertussis exposure is defined as face-to-face contact.
B. Do not return to school or work until 5 days of treatment are completed (no longer communicable).
C. Partially immunized or unimmunized infants are at high-risk.
D. Cough may persist for 6 months or more and will exacerbate with subsequent upper respiratory infections.
E. Avoid situations that trigger attacks.
F. Maintain hydration and nutrition.
G. Pertussis is highly contagious and is spread by droplet infection. Use careful handwashing technique and proper disposal of tissues.
H. Advise patient and family that epidemiologist will contact them for names of people who may have been exposed.
I. Adacel is available for people 11–64 years of age, Boostrix for those 10–18 years of age.
X. Follow-up
A. Maintain telephone follow-up in uncomplicated cases.
B. Return to office with any suspicion of complications.
XI. Complications
A. Respiratory
1. Bronchopneumonia: Significant fever, tachypnea
2. Atelectasis
3. Bronchiectasis
4. Pneumothorax
5. Interstitial or subcutaneous emphysema
B. Otitis media
C. CNS complications
1. Seizures
2. Coma
3. Hemiplegia, paraplegia
4. Ataxia
5. Blindness
6. Deafness
D. Secondary pressure effects during paroxysmal stage
1. Epistaxis
2. Melena
3. Petechiae
4. Subdural hematoma
5. Hernia, umbilical, inguinal
6. Rectal prolapse
XII. Consultation/referral
A. Consultation: All children with pertussis
B. Referral: All infants for hospitalization