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Pertussis

Pertussis. SUNY-Institute of Technology Carrie Warner, RN, FNP-S NUR 652 Family Primary Health Care 1. Pertussis - Whooping Cough.

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Pertussis

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  1. Pertussis SUNY-Institute of Technology Carrie Warner, RN, FNP-S NUR 652 Family Primary Health Care 1

  2. Pertussis -Whooping Cough • Pertussis is a highly contagious respiratory illness. In adolescents and adults, infection may result in a protracted cough and is occasionally associated with significant morbidity. In children, and particularly infants, morbidity can be significant and the disease may be fatal (Cornia & Lipsky, 2013). • Exclusively human pathogen. • Seen worldwide. • Endemic in the US with epidemic cycles. • High secondary attack rate in households.

  3. Pathophysiology: • Toxin-mediated. • Infectious process with preference for ciliated respiratory epithelium. • The bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions (CDC, 2013).

  4. Etiology: • Bordetella pertussis (responsible for 95% of cases) Bordetellapertussis bacteria (CDC, 2013) • B. parapertussis

  5. Incidence: • Estimated 48.5 million cases/year • Case fatality rate up to 4% in low-income countries • In 2004, more cases of pertussis occurred in adolescents and adults than in children (Cataletto, 2013)

  6. Pertussis cases are reported by states to CDC through the National NotifiableDiseases Surveillance System (NNDSS). Infants aged <1 year, continue to have the highest reported rate of pertussis. School-aged children 7-10 years continue to contribute a significant proportion of reported pertussis cases; however, 2012 data indicate that pertussis is increasing among adolescents 13 and 14 years of age (CDC, 2013).

  7. Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10NYCRR 2.10,2.14). According to the MMWR, found at www.cdc.gov/mmwr, as of the week ending September 15, 2013 there have been 15.864 cases of pertussis reported in the US, compared to 35,755 in 2012.

  8. Screening: • Review immunization records • Possible exposure/contacts

  9. Risk Factors: • Exposure to confirmed case: infects 80-90% of susceptible contacts. • Non or under-immunized children • Pregnancy • Premature birth • Age <4 months (these infants have the highest morbidity rate, complication rate, rate of hospitalization, and mortality rate) • Smokers • Patients with asthma • Immunodeficiency

  10. Clinical Findings: Incubation period is 5-21 days • Classic symptoms, more common in adolescent and adult cases, include: • paroxysmal cough • posttussive whoop • and/or vomiting. • Infants with pertussis may present with apnea

  11. Physical: Stage 1 Catarrhal: Usually 7-10 days; range of 4-21, Characterized by: • Rhinorrhea • Low-grade fever • Mild cough **The physical exam may be normal in the absence of paroxysms and clinical complications (Cataletto, 2013)

  12. Stage 2: Paroxysmal: Usually lasts 1-6 weeks, but may persist for up to 10 weeks, Characterized by: • Outbursts of numerous, rapid coughs due to difficulty expelling thick mucus from the tracheobronchial tree. • Long aspiratory effort accompanied by a high-pitched "whoop" at the end of the outbursts • Cyanosis • Vomiting and exhaustion (CDC, 2013)

  13. Stage 3: Convalescent: Lasts 1-2 weeks , Characterized by: • Gradual recovery • Less persistent, paroxysmal coughs that disappear in 2-3 weeks • Paroxysms often recur with subsequent respiratory infections for many months after the onset of pertussis. (CDC, 2013)

  14. Differential Diagnosis: • Includes a wide range of respiratory viruses • B. parapertussis and RSV • Other infectious causes of prolonged cough include: • M. pneumonia • Chlamydia trachomatis • C. pneumonia • B. bronchiseptica • adenovirus. • Sinusitis • Airway, foreign body

  15. Social/Environmental Considerations: • Prevention with Immunization • Early treatment with strong suspicion or confirmation • Early case reporting • Contact precautions or quarantine for those involved in care or who may have been exposed • Prophylactic 5 day course of antibiotic for close contacts • (Cataletto, 2013)

  16. Laboratory Tests • Lab tests: • If within 3 weeks of onset of cough, send nasopharyngeal aspirate for polymerase chain reaction (PCR) and culture. • PCR results come back sooner- Culture remains the gold standard. • If less than 2 weeks from onset of symptoms, consider serum pertussis toxin IgG. • Imaging: • Chest x-ray: may be normal or show signs of hyperinflation. Pneumonia may also be present. (Cataletto, 2013)

  17. Laboratory Tests: • Culture: Use calcium alginate swabs • PCR: Use Dacron swabs

  18. Management/Treatment Guidelines: • Pharmacological: Macrolides • Short term treatment with azithromycin or clarithromycin or erythromycin has been found to be as effective as a 10-14 day course of erythromycin. • Trimethoprim-sulfamethoxazole can used as an alternative when macrolides are not appropriate(Cataletto, 2013)

  19. Management/Treatment Guidelines: • Non-pharmacological: • Supportive care is the mainstay of management for B. pertussis infection. Supportive care may include hospitalization for close monitoring of respiratory status and fluid or nutritional support. In addition, known triggers for coughing paroxysms (exercise, cold temperatures, nasopharyngeal suctioning) should be avoided (Yeh, 2013).

  20. Complications:Infants and Children • Pertussis can cause serious and potentially life-threatening complications in infants and young children who are not fully vaccinated. • In infants younger than 12 months of age who get pertussis, more than half must be hospitalized. • Hospitalization is most common in infants younger than 6 months of age. • Complications: • apnea • pneumonia • seizures • 1% will die

  21. Of those infants younger than 12 months of age who die:Refractory pulmonary hypertension is a common, severe complication that contributes to death.Encephalopathy occurs in approx20% of cases (Yeh, 2013).

  22. Other complications can include: • anorexia dehydration • difficulty sleeping epistaxis • Hernias otitis media • urinary incontinence • Severe complications can include: • pneumothorax • rectal prolapse • subdural hematomas

  23. Complications: Adolescents and Adults Less severe: especially in those who have been vaccinated. Much less incidence of hospitalization. Common complications: Weight loss Urinary incontinence Syncope Rib fractures from severe coughing AnorexiaDehydration Epistaxis Hernias Otitis media More severe complications can include encephalopathy as a result of hypoxia from coughing or possibly from toxin, pneumothorax, rectal prolapse, subdural hematomas, and seizures. (CDC, 2013)

  24. Follow-up: • As needed for complications • Infants under 1 month of age who received treatment with a macrolide antibiotic should be monitored for 1 month for idiopathic hypertrophic pyloric stenosis • Make sure vaccination and booster schedule is maintained

  25. Counseling/Education: Highly contagious-Treat close contacts Vaccinate Coughing fits due to pertussis infection can last for up to 10 weeks or more; sometimes known as the "100 day cough.“ www.aap.org www.cdc.gov

  26. Post-exposure Prophylaxis (PEP) CDC (2013) supports targeting post-exposure antibiotic use to persons at high risk of developing severe pertussis and to persons who will have close contact with those at high risk of developing severe pertussis. This includes: • Infants and women in their third trimester of pregnancy • All persons with pre-existing health conditions that may be exacerbated by a pertussis infection • Contacts who themselves have close contact with either infants under 12 months, pregnant women or individuals with pre-existing health conditions at risk of severe illness or complications. • All contacts in high risk settings that include infants aged <12 months or women in the third trimester of pregnancy. (NICU, childcare settings, and maternity wards.)

  27. Consultations/Referral: • Hospitalization for infants • Pediatric infectious disease consult • Neurologic and/or pulmonary follow-up or referral as necessary

  28. Questions 1) Pertussis has three stages of the disease process. They are: • paroxysmal, convalescent, abysmal • catarrhal, paroxysmal, convalescent • convalescent, immunization, catarrhal • Pre-pertussive, pertussive, post-pertussive, 2) Pertussis is: • a highly contagious bacterial infection • transmitted by respiratory droplets • always treated at home • all of the above • A, B 3) Complications of pertussis can include: • Rib fracture • Epistaxis • Otitis media • All of the above

  29. Questions 4) First line treatment of pertussis: • Macrolide antibiotics • Metronidazole • Antihistamines • Corticosteroids 5) The bacteria responsible for about 95% of the cases of pertussis is: • Chlamydia trachomatis • C. pneumonia • Bordetella pertussis • B. parapetussis 6) The “Gold Standard” of testing is: • Chest x-ray • PCR • Serum pertussis toxin IgG • Culture

  30. Questions 7) Complications that can lead to hospitalization of infants include: • Otitis media • Apnea • Seizures • B & C • A & B 8) Paroxysmal stage includes: • Rhinorrhea, mild cough, low-grade fever • Decreasing severity of coughing paroxysms • Cough becomes paroxysmal, increasing in severity and frequency • Immunization completion 9) Pertussis is spread by: • Respiratory droplets • Coughing • Sneezing • All of the above 10) Older children and adults with pertussis will most likely: • Be hospitalized • Acquire the disease from an immunized infant/child • Have not had a recent Adacel shot • Have no history of asthma

  31. Answers: 1) B 6) D 2) E 7) D 3) D 8) C 4) A 9) D 5) C 10) C

  32. References: Cataletto, M. (2013). Pertussis. The 5-Minute clinical consult 2013 (21st edition). New York, NY: Lippincott, Williams, & Wilkins. CDC (2013). Pertussis. Retrieved from http://www.cdc.gov/pertussis/clinical/diseasespecifics.html Cornia, P. & Lipsky, M. (2013). Treatment and prevention of bordetellapertussis infection in adolescents and adults. Retrieved from www.uptodate.com UTD (2013). Pertussis treatment guidelines. Retrieved from http://www.uptodate.com/ Yeh, S. (2013). Treatment and prevention of bordetellapertussis infection in infants and children. Retrieved from http://www.uptodate.com/

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