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PED-EM-L  January 2011

PED-EM-L January 2011

Subject:

Re: pertussis

From:

Peter Auerbach <[log in to unmask]>

Reply-To:

[log in to unmask]

Date:

Sun, 9 Jan 2011 16:51:58 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (197 lines)

Funny, I just finished preparing a lecture on this topic 
(primarily bronchiolitis, but with a tangent on "What about Pertussis?").

I've discussed the question of who to test, and who to consider treating, with our ID people, 


and gotten recent data from the CDC and the Oregon DHS Public Health Division

and I'm going to reproduce my slides on this question below.

By way of brief background, everyone gets/can get Pertussis (as it remains endemic and immunity from vaccination is not 100%, and decreases with time), and there's been a huge upswing this year in positive tests/known cases in the U.S., particularly in certain states


(most notably California, which is seeing more cases than at any time since vaccination 1947),

though it's not clear why, and to what degree this is due to increased awareness and increased testing vs. a true increase in cases.

What is clear is that the population most affected is very young infants, which is where the overlap with bronchiolitis exists.




That said, the main difference clinically is that bronchiolitis is a clinical diagnosis, based on hx. (usually very brief -- i.e. several day max. -- duration of URI sx's, then progressing to lower respiratory tract involvement, which is usually why parents bring the infants in for evaluation) and PE findings of lower respiratory tract involvement and increased work of breathing (tachypnea, retractions, abnormal "crackly" breath sounds, etc.).




Infants with pertussis, in contrast, do not typically exhibit lower respiratory tract involvement (only the very rare, sickest young infants develop pneumonia as a complication) and, in fact, are often asymptomatic when seen in the ED (and are brought for a h/o "bad cough", though some may have more classic "whooping" and the very rare one may actually be significantly sick or in distress -- this is very uncommon though).




To restate the above: 

The Hx. and PE should be enough to classify infants (the population that really matters the most in terms of morbidity and mortality) into either: 
(1) clinically has bronchiolitis, OR 


(2) consider pertussis (and therefore test).  
There is not much overlap between the groups.  
Also, there's no rapid pertussis test like there is for RSV (though you don't need to test for RSV to dx. bronchiolitis, and should avoid doing so unless there's a specific reason), so the test should only be sent on the appropriate patients.




If (2) consider pertussis, then the next question is: 
who to empirically treat (with azithromycin) while awaiting the result.  
The short answer is, it depends upon how likely you think the dx. is, and how young the infant is (under 6 months?  I don't think there's a standardized answer to this question).




Here are my slides on pertussis (from within my larger talk on bronchiolitis):

(1) What about Pertussis?
*One of the most common childhood illnesses in the U.S. in the 20th century
*Before vaccination > 200,000 cases/year


*Since vaccination in 1940's, > 80% decreased incidence
*Still an endemic infection in the U.S. (not "vaccine eradicatable")
*Increasingly prevalent
*Highest morbidity in young children

(2) Why does it matter now?


*Signifiantly increasing prevalence in the U.S., particularly in certain states (such as California)
[graphical data from the CDC, California and Oregon]

(3) Pertussis Among Adolescents and Adults
*Often milder than in infants and children


*May be asymptomatic, or may present as classic pertussis
*Persons with mild disease (we never know they have it) may transmit the infection to others
*Older persons often the source of infection for children



(4) Reported (perhaps not actual) incidence by age decreases as age goes up
*Highest (reported) incidence in young children
*Decreased (reported) incidence decreases with each DTaP vaccination (2 - 4 - 6 months)



(5) Diagnosis of Pertussis
*High clinical suspicion (but only the right patients)
*Cough > 2 weeks
*No significant fever
*Post-tussive emesis
*Close contact with others with prolonged cough
*Looks fine in the ED (no sig. sx's) -- i.e. DO NOT CLINICALLY HAVE BRONCHIOLITIS



(6) Diagnosis of Pertussis
*Culture is gold standard, though expensive and time-consuming
*PCR is faster with good sensitivity
*Classic WBC elevation with lymphocytosis only occurs in infants and is unreliable (DO NOT CHECK CBC TO ESTABLISH OR SUPPORT DX.)



(7) Treatment of Pertussis
*Supportive care
*Azithromycin (standard treatment)
*Trimethoprim-Sulfamethoxazole (alternative to azithromycin)
*Antibiotics do NOT shorten the course of illness, they only (potentially) reduce contagion



(8) Who to Test?  (KEY SLIDE, though same as "5" above)
*Cough > 2 weeks
*Coughing "fits"
*No significant fever
*Post-tussive emesis
*Close contact with others with prolonged cough


*Looks fine in ED

(9) Who to Treat (while awaiting PCR result) -- also KEY SLIDE
*Difficult question
*Under 6 months(?), due to risk of immediate complications if treatment delayed (unlike older children and adults)


*High likelihood of disease

(10) Tdap
*All persons > 10 years old considered susceptible to pertussis due to waning immunity unless given single dose of Tdap
*Single dose of Tdap to replace Td booster 


*Special emphasis on adults with close contact with infants (including childcare and ALL healthcare personnel, and parents)
*The purpose of giving everyone Tdap over age 10 is to decrease the spread of asymptomatic carriers in the community



(11) Summary of Pertussis
*Far more common than usually suspected
*Must be considered to be diagnosed
*Matters mostly for infants
*Dramatically increasing in (reported) incidence throughout the U.S.
*You are likely to see it if you look for it!


*Does NOT look like bronchiolitis!


If anyone has gotten this far, here is where I am now:

Peter S. Auerbach, MD, FAAEM, FAAP
Pediatric Emergency Medicine
Northwest Acute Care Specialists


The Children's Hospital at Legacy Emanuel
Portland, OR




On Sun, Jan 9, 2011 at 11:57 AM, Fergus Thornton <[log in to unmask]> wrote:



I was wondering what some of you do about testing for pertussis.  It's winter and I'm




seeing lots of bronchiolitis but maybe some of these are pertussis but I can't test all of them.

I'm pretty good at picking this up in adults but infants?  I'm not sure.  Some guidance would be helpful.  Thanks.



Fergus Thornton



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