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بسم الله الرحمن الرحیم. Powerpoint Templates. Bordetella pertussis. http://www.hhmi.princeton.edu/sw/2002/psidelsk/Microlinks.htm. Roxana M.Ghanaie Ped Infectious Disease Subspecialist. Aerobic, Gram negative coccobacillus Alcaligenaceae Family Specific to Humans

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  1. بسم الله الرحمن الرحیم Powerpoint Templates

  2. Bordetella pertussis http://www.hhmi.princeton.edu/sw/2002/psidelsk/Microlinks.htm Roxana M.Ghanaie Ped Infectious Disease Subspecialist

  3. Aerobic, Gram negative coccobacillus Alcaligenaceae Family Specific to Humans Colonizes the respiratory tract Whooping Cough (Pertussis) Bordetella pertussis Basics

  4. Bordetella pertussis is a bacterium identified in 1900 by Jules Bordet and Octave Gengou but isolated only in 1906 because of the development of a medium containing potatoes extract and rabbit blood Jules Bordet 1870-1961

  5. Why speaking about Pertussis? • Iran pertussis incidence 2010 : 0.5/ 100000 • DTP3 coverage more than 95%

  6. Estimated annual childhood deaths, 2002 Meningococcal (< 1%) rotavirus (16%) pneumococcal (28%) measles (21%) 24% 76% Hib (15%) pertussis (11%) tetanus (8%) { yellow fever (1%) diphtheria (<1%) polio (< 1%) 10.5 million deaths under 5 years of age 1.4 million from diseases where vaccination is currently available 1.1 million from diseases where vaccines will be available by 2008 Source: WHO/IVB

  7. Classic Manifestation • The incubation period of pertussis is usually 7 to 10 days, with a range of 4 to 21 days. • “The cough of 100 days”,China,The clinical course of illness is divided into three stages.( age, vaccination, waning) • The catarrhal stage is characterized by the onset of runny nose, sneezing, low-grade fever, and a mild cough. Cough gradually becomes more severe (1-2 weeks)

  8. Classic Manifestation • The paroxysmal stage is characterized by coughing fits (paroxysms), which may be followed by a high-pitched inspiratory whoop, vomiting, and/or apnea. (1-6 weeks), but may continue for 10 weeks • The convalescent stage is characterized by fewer paroxysmal coughing episodes and usually disappears in 2-3 weeks, but may continue for months.

  9. Complications • Losing weight, pneumonia, otitis, seizure, encephalopathy, apnea • Epistaxia, melena, subdural hematoma, inguinal hernia, rectal prolapse,

  10. Infants • The severity of pertussis and the rapidity of its progression in young infants is effected by a number of factors such as: • the presence of transplacentally acquired maternal antibodies to B. pertussis, • the infectious dose of bacteria that the infant receives, • co-infection with respiratory viruses and perhaps genetic factors related to the pathogen or the infant.

  11. Infants • Short catarrhal period, longer convalescence period • Cough,feeding abn, res distress,apnea,cyanosis, bradycardia, whoop uncommon, • paroxysms and this may lead to apnea, gasp, hypoxia and occasionally seizures • Initially the chest is clear on auscultation but in fatal cases B. pertussis pneumonia is always present. • Co-infection with respiratory viruses (particularly RSV and adenoviruses) can confuse the diagnoses because of a bronchiolitic picture (air trapping and expiratory distress).

  12. Accounts for up to 7-30% of cough illnesses per year Disease often milder than in infants and children Infection may be asymptomatic, or may present as classic pertussis Cough may last 21 d, st. paroxysmal Pertussis Among Adolescents and Adults

  13. Clinical manifestation in immunized • Mild , unrecognized cough • Prolonged cough • Persons with mild disease may transmit the infection • Older persons often source of infection for children • Adults: sleep disturbances, syncope, incontinence, rib Fx,pneumonia

  14. Definition: Clinical Case Definition of Pertussis • A cough illness lasting at least 14 days with one of the following: • paroxysms of coughing, • inspiratory “whoop”, • or post-tussive vomiting, • and without other apparent cause (as reported by a health professional).

  15. Definition: Laboratory Criteria for Pertussis Diagnosis • Isolation of Bordetella pertussis from a clinical specimen (culture positive), or • Positive polymerase chain reaction (PCR) assay for B. pertussis DNA. Note: Serological testing for B. pertussis is not standardized • Serology and DFA results should not be relied on as a criterion for laboratory confirmation of pertussis.

  16. Pertussis Case Classification • Confirmed: • a. A positive culture for B. pertussis and an acute cough illness of any duration, or • b. Meets the clinical case definition and is confirmed by PCR, or • c. Meets the clinical definition and is epidemiologically linked directly to a case confirmed by either culture or PCR. • Probable: A case that meets the clinical case definition, is not laboratory confirmed, and is not epidemiologically linked to a laboratory-confirmed case; also includes cases meeting the outbreak case definition

  17. Outbreaks • Outbreak: Two or more cases involving two or more households clustered in time (e.g., occurring within 42 days of each other) and either epi-linked or sharing a common space (e.g., in one building) where transmission is suspected to have occurred (e.g. a school). • One case in an outbreak must be lab confirmed (PCR positive and meets case definition, or culture positive). In an outbreak setting, a case may be defined as an acute cough illness lasting ≥ 2 weeks without other symptoms.

  18. Very Contagious, 80% secondary attack rate among susceptible persons( even immunized) Transmission occurs via respiratory droplets, direct contact with respiratory secretions from infected individuals Parents are a common source of B. pertussis infections for infants, grandparents, uncles , Aunts also provide another potential source of infection Transmission

  19. Transmission Pertussis Infectious Period: • Most infectious during the catarrhal (early) stage. • Infectious during the first 21 days of cough if not treated with appropriate antibiotic. • No longer infectious after 5 days of treatment with appropriate antibiotic • Length of communicability: age, immunization status, appropirate antibiotic therapy • Isolation: standard, droplet

  20. B. parapertussis • B. parapertussis infection in humans can cause unrecognized infection, mild pertussis, or classic pertussis • B. bronchisepica

  21. DD prolonged cough • Adenovirus • Para influenza • Influenza A,B • M.pneumonia • RSV • C.trachomatis • C. pneumonia

  22. DD • Laboratory confirmation of pertussis is difficult and delayed. Therefore, clinicians need to make the diagnosis of • pertussis presumptively in patients with a history of intense paroxysmal coughing with or without whooping, color changes, posttussive vomiting, incomplete or absent pertussis vaccination, and finding of lymphocytosis on laboratory examination.

  23. DD prolonged cough • spasmodic attacks of coughing may be observed in children with: • bronchiolitis, bacterial pneumonia, cystic fibrosis, or tuberculosis. Afebrile Pneumonia Syndrome • The cough associated with: sinusitis, airway foreign body

  24. CXR Indications • 1/ <1y • 2/ toxic • 3/ progressive cough>3 w • 4/ res distress • 5/ probable underlying dis( CF, CHD,forign body, Hilar LAD)

  25. Chest Xray • Most common : Normal • Shaggy heart( central airway not periph) • Hyperinflation, hyper lucent lung • Micro athelectasia • Secondary bac. Pneumonia • Bronchiolitis oblitrans( adeno, influ, measles, pertussis) • pneumothorax

  26. Management: • The desired outcomes are: limiting the number of paroxysms, observing the severity of cough, providing assistance when necessary, and maximizing nutrition, rest, and recovery, follow the course of dis., prevent/treat complications

  27. Admitt: 1- all infants<3 m despite severity & all 3-6 m except the attacks are mild as observed by physician 2- with complications(intractable nausea and vomiting, failure to thrive,seizures, encephalopathy, or for patients with sustained hypoxemia during coughing paroxysms who require supplemental oxygen,) hx of prematurity in infant, with underlying cardiac, pul, neuromuscular dis

  28. Management • For the hospitalized patient, in addition to standard precautions, droplet precautions are recommended • Monitor heart rate, respiratory rate, and oxygen saturation of hospitalized patients continuously,especially in relation to coughing paroxysms. Coughing, feeding, vomiting, and weight changes should be recorded.

  29. Management: • Oxygen,suction,hydration, nutrition • Patients who are severely ill may require treatment in an ICU. • Investigate all probable, pertussis reports. Evaluate whether reported case’s symptoms are compatible with pertussis • Recommend antibiotics for the index case (first case reported to public health authorities), all household and close contacts. Antibiotic inspite of age, immunization Hx

  30. Report & find contacts • Only confirmed and probable cases are reported. • Recommend DTaP/Tdap vaccination according to appropriate age for exposed children, adolescents and adults. • Exposed children < 7 years of age whose last DTP( 4th dose) was more than 3 years ago should be vaccinated.( more than 6m after 3rd dose)

  31. Report & find contacts • Evaluate close contacts for pertussis symptoms, and when possible collect specimens for lab testing from symptomatic persons • Vaccine after discharge: If documented disease, do not need additional doses of pertussis vaccine Satisfactory documentation of disease: recovery of B. pertussis on culture, OR typical symptoms and clinical course when epidemiologically linked to a culture- proven case

  32. During catarrhal stage ameliorate disease After cough establishment, does not generally lessen duration; protect others Limited benefit if begun >21 days after onset/exposure Exception: high risk cases/contacts - treat up to 6 weeks Treatment (cont)

  33. Treatment • Antibiotic therapy • Erythromycin • Azithromycin • Clarithromycin http://www.aboutthatbug.com/AboutThatBug/files/CCLIBRARYFILES/ FILENAME/0000000032/033_lg.jpg http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/macrohd.htm

  34. Treatment Erythromycin For children: 40-50 mg/kg/d in 4 divided doses;10-14 days • For adults: 1 to 2 g/day given every 6 h has

  35. Treatment Azithromycin • for children: at 10 mg/kg on day 1 and 5 mg/kg on days 2 to 5 as a single dose for 5 days • 10-12 mg/kg/d PO in 1 dose for a total of 5 days. ( < 6m) • for adults: 500 mg on day 1 and 250 mg on days2 to 5

  36. Treatment Clarithromycin • for children: at 15 to 20 mg/kg/day in two divided doses for 7 days • for adults: 1 g/day in two doses for 7 days

  37. Trimethoprim(T)/Sulfamethoxazole (S) 8mg/kg T + 40 mg/kg S/d in 2 divided doses; 14 days Erythromycin and clarithromycin are not recommended in infants younger than 4-6 w because their use has been associated with increased risk for infantile hypertrophic pyloric stenosis (IHPS). Resistant to macrolid: rare Cephalosporine, PN not effective Treatments

  38. Treatment • Humans infected withB. parapertussis or B. holmesii • macrolide therapy indicated above. • In contrast, however, B. bronchiseptica is usually resistant to Erythromycin Most sensitive to aminoglycosides, extended-spectrum third-generation penicillins, tetracyclines, quinolones, and trimethoprim-sulfamethoxazole.

  39. Treatment • It has been observed in numerous small studies that pertussis infant deaths relate directly to the degree of leukocytosis • double volume exchange transfusion, to lower the white blood cell count

  40. Treatment • Pertussis-specific immune globulin is an investigational product that may be effective in decreasing paroxysms of cough but requires further evaluation. • The use of corticosteroids, albuterol, and other beta2-adrenergic agents for the treatment of pertussis is not supported by controlled, prospective data

  41. Symptomatic: first 5 days of treatment Symptomatic, refuses treatment: exclude for 21 days from onset of symptoms Asymptomatic exposure: no exclusion Exclusions fromwork/school

  42. Complications in Infants • Pneumonia( in 22% infants) • Seizures( in 2% infants) • Encephalopathy( less than 0.5% infants) • FTT,Death 0.3%( 1% in less than 2 m-old) • SIDS( ???)

  43. Prognosis • Prognosis for full recovery is excellent; however, patients with comorbid conditions as previously described have a higher risk of morbidity and mortality • Leukocytosis, particularly WBC counts of more than 100,000, has been associated with fatalities from pertussis. • Another study showed that WBC counts of more than 55, 000 and pertussis complicated by pneumonia were independent predictors of fatal outcome in a multivariate model.

  44. Close contacts: Household contacts; Other persons having direct prolonged exposure to the case while case was contagious and was coughing or sneezing. 1. Direct face-to-face contact for an undefined time period with an infectious pertussis case (case coughing < 21 days and has not completed 5 days of appropriate antibiotic treatment). Use a narrow definition ofclose contact

  45. 2. . Shared confined space in close proximity for a prolonged period of time, such as ≥ 1 hour, with an infectious pertussis case. For example, riding in a car with a pertussis case. 3. Direct contact with respiratory, oral, or nasal secretions from an infectious pertussis case (e.g., an explosive cough or sneeze in the face, sharing food, sharing eating utensils, kissing, mouth-to-mouth resuscitation, or performing a full medical exam including examination of the nose and throat without wearing a mask). Summary of Pertussis Investigation and Control Guidelines Colorado Department of Public Health and Environment Communicable Disease Epidemiology Program Use a narrow definition ofclose contact

  46. Exposed • Household, close contacts, health care worker: • Check immunization, initiate, complete • Chemopx for all contacts regardless age, immunization • If start later than 21 d after exposure, give only to highrisk: young infant, pregnant, care taker of infants • Monitor for 21 d after last contact, for symptoms • Evalute symptomatic exposed persons and exclude from public setting and report confirmed, probable cases

  47. QUESTIONS?

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