Clinical Practice Guidelines

Whooping cough (pertussis)


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • Background

    • Caused by the bacterium Bordetella pertussis (occasionally Bordetella parapertussis)
    • Infants less than 6 months of age are at greatest risk of complications (apnoea, severe pneumonia, encephalopathy) and are most commonly infected by spread from family members.
    • Can occur in immunised children but the illness is generally less severe.
    • Patients are infectious just prior to and for 21 days after the onset of cough, if untreated.

    Assessment

    Diagnosis is largely clinical.

    History:

    • Classic whooping cough: Cough and coryza for one week (catarrhal phase), followed by a more pronounced cough in spells or paroxysms (paroxysmal phase).
    • Pertussis can also present as a non-specific persistent cough
    • Vomiting often follows a coughing spasm.
    • Infants may develop apnoea and/or cyanosis with coughing spasms.
    • Close contact with a case of Pertussis may raise suspicion.
    • Other family members frequently have a cough (>70% of household contacts are also infected).

    Examination:

    • Often, there are no clinical signs. Children are usually well between coughing spasms.
    • Observation of coughing spasms may be helpful
    • Fever is uncommon.

    Investigations:

    • Laboratory confirmation is not necessary for diagnosis, but may be helpful for infection control.
    • A nasopharyngeal aspirate/swab for PCR is the investigation of choice. The test is usually negative after 21 days, or 5-7 days after effective antibiotic therapy has been commenced.
    • Pertussis serology (IgA) may be detectable 2 weeks after the onset of the illness but rarely affects clinical management.

    Management of patient

    Antibiotics

    Consider antibiotics if:

    • Diagnosed in catarrhal or early paroxysmal phase (may reduce severity)
    • Cough for less than 14 days (may reduce spread; reduces school exclusion period)
    • Admitted to hospital
    • Complications (pneumonia, cyanosis, apnoea)

    Antibiotic options:

    • Neonates
      • Azithromycin 10 mg/kg oral daily for 5 days
    • Children who cannot swallow tablets:
      • Clarithromycin liquid 7.5 mg/kg/dose (max 500mg) oral BD for 7 days
    • Children who can swallow tablets:
      • Azithromycin (for children = 6 months old): 10mg/kg (max 500 mg) oral on day 1, then 5mg/kg (max 250mg) daily for 4 days
    • If macrolides are contraindicated:
      • Trimethoprim-sulphamethoxazole (8mg-40mg per ml)
        • 0.5ml/kg (max 20ml) BD for 7 days

    Control of diagnosed case

    • Exclude from school and presence of others outside the home (especially infants and young children) until received 5 days of therapy, or coughing for more than 21 days.

    Vaccination

    • Unimmunised or partially immunised children diagnosed with pertussis should still complete the pertussis immunisation schedule.

    Notification

    Notify all cases (suspected or confirmed) of pertussis to the Communicable Diseases Section, DHS, Victoria. Tel: 1300 651 160 or Fax: 1300 651 170.

    DHS information on pertussis
    Notification info, and notification form


    Treatment of contacts

    Antibiotic Prophylaxis:

    Notes:

    • Prophylaxis is aimed at preventing spread to infants <6 months.
    • There is little evidence that antibiotics prevent transmission outside of household settings, and side effects (especially gastrointestinal) are relatively common.
    • Transmission requires close contact (exposure within 1 metre for more than 1 hour) but can be less for young infants.
    • Most school-aged children who are fully vaccinated and do not have symptoms do not require prophylaxis.
    • Management of immunodeficient contacts should be made on a case by case basis.
    • Management of outbreaks may differ from below and will be conducted by DHS.

    Prophylaxis table: 

    Antibiotics   No antibiotics
     Close contact with confirmed case of pertussis whilst index case infectious (< 21 days of cough and < 5 days effective antibiotics)
    AND
     Contact with index case while no longer infectious ( > 21 days of cough and >5 days effective antibiotics)
    OR
     First contact was within 14 days (or within 21 days for infants < 6 months)
    AND
     First contact was > 14 days (or > 21 days for infants < 6 months)
     Children:
    • Age <6 months OR
    •  <3 doses pertussis vaccine OR
    •  Household member age <6 months OR
    •  Attend childcare in same room as infant <6 months

    Adults (regardless of immunisation status)

    • Expectant parents in last month of pregnancy OR
    • Health care worker in maternity hospital or newborn nursery OR
    • Childcare worker in close contact with infants <6 months OR
    • Household member aged <6 months


    Antibiotic options:

    • Prophylaxis regimen same as for treatment (refer above)

    Vaccination:

    • Close contacts that are not up to date with their pertussis immunisation should be given DTPa or dTpa as soon after exposure as possible.
    • Consider dTpa for adults who have not had pertussis-containing vaccine in the last 10 years.

    School exclusion:

    • Unimmunised (< 3 doses) household and close childcare contacts less than 7 years of age must be excluded from school or child care for 14 days from the last exposure to infection OR until they have taken 5 days of effective antibiotics.

    When to admit/consult local paediatric team: 

    • Infants less than 6 months of age
    • Any child with complications (apnoea, cyanosis, pneumonia, encephalopathy)

    When to consider transfer to tertiary centre:

    • Any child with complications (apnoea, cyanosis, pneumonia, encephalopathy)

      For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Parent information sheet

    Information specific for RCH

    Specimen collection and results:

    Pertussis PCR testing: Send dry (non-charcoal or flocked swabs) from nasopharynx (preferably) or nose, or nasopharyngeal aspirate (NPA)
    Monday-Friday: specimens received in lab by 10am reported by 2pm. Specimens received by 2pm reported by 5pm. Saturday: Specimens received by 10am reported by 2pm. Sunday: No routine testing.