Although tetracycline and chloramphenicol are effective treatments for pertussis, they are not recommended because of their side effects.1 Six randomized trials failed to show any statistically significant difference between antibiotics and placebo on frequency and severity of cough or duration of pertussis disease.1 A randomized, placebo-controlled trial studied 300 household contacts of children with culture-positive pertussis. There was no statistically significant difference in either the frequency of pertussis disease or rate of positive cultures in household contacts between the erythromycin group (2.1%) and the placebo group (5.1%) (ARR=2.95%; 95% CI, –1.21 to 7.11).1
Another Cochrane review of 8 trials examined the effectiveness of the symptomatic treatment of cough in children and adults with pertussis. There were many problems with the methodological quality of these trials, including small sample sizes and poor reporting of the methods. Diphenhydramine, pertussis immunoglobulin, corticosteroids and salbutamol were compared with placebo. There were no statistically significant differences in coughing paroxysms, mean number of whoops per 24 hours or in duration of hospital stay between these interventions and placebo.3
Extracorporeal circulatory life support has been used to maintain perfusion for patients with severe disease. The mortality of these patients is very high.4 No RCTs of the effectiveness of this intervention has been performed.
TABLE
Antibiotics for treatment and prophylaxis of pertussis in children and adults
| FIRST-LINE THERAPY | DOSAGE FOR CHILDREN | DOSAGE FOR ADULTS | COST* |
|---|---|---|---|
| Erythromycin | 40-50 mg/kg orally or intravenously in 4 divided doses for 14 days5,7 | 1–2 g orally or intravenously in 4 divided doses for 14 days5,7 | 56 tabs (500 mg), $16 (generic) |
| ALTERNATIVE THERAPY IF PATIENT DOESN’T TOLERATE ERYTHROMYCIN | |||
| Clarithromycin | 15-20 mg/per kg orally divided every 12 hours for 10-14 days7or 14-15 mg/kg orally divided every 12 hours for 7 days1,5 | 500 mg orally every 12 hours for 7 days5 | 20 tabs (500 mg), $78 28 tabs (500 mg), $109 (generic) |
| Azithromycin | 10-12 mg/kg orally as single daily dose for 5 to 7 days5,7or 10 mg/kg orally single daily dose for 3 days1 | 500 mg orally once, then 250 daily on days 2-55,7 | 5 tabs (500 mg), $75 7 tabs (500 mg), $105 (no generic) |
| Trimethoprim-sulfamethoxazole | 8 mg of TMP, 40 mg/kg SMX per kg orally divided every 12 hours for 14 days5,7 | 160 mg of TMP, 800 SMX orally (1 tab DS) every 12 hours for 14 days5,7 | 28 tabs $8 (generic) |
| All these therapies have gastrointestinal side effects and risk for hypersensitivity reactions. | |||
| *Approximate retail price for adult dose. Available at: http://www.drugstore.com. Accessed on June 28, 2005. | |||
Recommendations from others
The Centers for Disease Control and Prevention recommends erythromycin for 14 days as a first choice for the treatment and prophylaxis of pertussis. Antibiotics should be started no later than 3 weeks after the onset of cough. Trimethoprim-sulfamethoxazole can be used as an alternative treatment for patients who do not tolerate erythromycin. Prophylaxis is recommended for all household and close contacts if pertussis is highly suspected.5
The American Academy of Pediatrics recommends the use of azithromycin and clarithromycin as an alternative treatment for patients who do not tolerate erythromycin. 5
A national consensus conference on pertussis held in Canada recommended prophylaxis for household contacts of an infant aged <1 year, pregnant women during the third trimester, and for vulnerable individuals who have had face-to-face exposure, or have shared confined air for >1 hour.6