Immunogenicity of tetanus, diphtheria and acellular pertussis vaccination among pregnant women living with and without HIV

OBJECTIVE

Vaccination during pregnancy with tetanus-diphtheria-acellular pertussis (Tdap) vaccine is recommended to protect the young infants against pertussis. There is a paucity of data on immune responses to Tdap in pregnant women with HIV (PWWH), and its impact on the protection of their infants has not been described.

METHODS

In an open label phase IV clinical trial in South Africa, we evaluated the immunogenicity and safety of Tdap in PWWH compared with HIV-uninfected women. Antigen-specific immunoglobulin G (IgG) to pertussis toxoid, filamentous haemagglutinin, pertactin, fimbriae, diphtheria and tetanus were measured by electrochemiluminescence-based multiplex assay.

RESULTS

Overall, 91 PWWH and 136 HIV-uninfected pregnant women were enrolled. All PWWH were on antiretroviral treatment and 94.5% had HIV viral loads <40 copies per millilitre. Antibody levels prevaccination were lower among PWWH compared with HIV-uninfected women for all antigens. At 1 month postvaccination PWWH compared with HIV-uninfected women had lower fold-increase and antibody concentrations for all epitopes. Also, a lower proportion of PWWH achieved ≥4-fold increase from pre to postvaccination for pertussis toxoid and pertactin, or diphtheria IgG levels ≥0.1 IU/ml and ≥1 IU/ml postvaccination. Adverse events postvaccination were similar in PWWH and HIV-uninfected.

CONCLUSION

Tdap vaccination was safe and immunogenic. PWHW had, however, attenuated humoral immune responses, which could affect the effectiveness of protecting their infants against pertussis compared with those born to women without HIV.ClinicalTrials.gov identifier: NCT05264662.

The incidence, duration, risk factors, and age-based variation of missed opportunities to diagnose pertussis: A population-based cohort study

OBJECTIVE

To estimate the incidence, duration and risk factors for diagnostic delays associated with pertussis.

DESIGN

We used longitudinal retrospective insurance claims from the Marketscan Commercial Claims and Encounters, Medicare Supplemental (2001-2020), and Multi-State Medicaid (2014-2018) databases.

SETTING

Inpatient, emergency department, and outpatient visits.

PATIENTS

The study included patients diagnosed with pertussis (International Classification of Diseases [ICD] codes) and receipt of macrolide antibiotic treatment.

METHODS

We estimated the number of visits with pertussis-related symptoms before diagnosis beyond that expected in the absence of diagnostic delays. Using a bootstrapping approach, we estimated the number of visits representing a delay, the number of missed diagnostic opportunities per patient, and the duration of delays. Results were stratified by age groups. We also used a logistic regression model to evaluate potential factors associated with delay.

RESULTS

We identified 20,828 patients meeting inclusion criteria. On average, patients had almost 2 missed opportunities prior to diagnosis, and delay duration was 12 days. Across age groups, the percentage of patients experiencing a delay ranged from 29.7% to 37.6%. The duration of delays increased considerably with age from an average of 5.6 days for patients aged <2 years to 13.8 days for patients aged ≥18 years. Factors associated with increased risk of delays included emergency department visits, telehealth visits, and recent prescriptions for antibiotics not effective against pertussis.

CONCLUSIONS

Diagnostic delays for pertussis are frequent. More work is needed to decrease diagnostic delays, especially among adults. Earlier case identification may play an important role in the response to outbreaks by facilitating treatment, isolation, and improved contact tracing.

Whole-Cell and Acellular Pertussis Vaccine: Reflections on Efficacy

Pertussis is a common respiratory infection caused by the bacterium Bordetella pertussis. Although most cases occur in developing countries, it is considered endemic globally. The World Health Organization estimates there are 20-40 million cases of pertussis annually. Pertussis vaccines played a pivotal role in reducing the burden of pertussis disease as well as infant morbidity and mortality. Although the two forms of pertussis vaccine are effective, each has its advantages and drawbacks. This review aims to review the current knowledge on pertussis vaccines, emphasizing vaccine effectiveness in different populations within a community. Clinical trials have shown favorable vaccine efficacy with acellular pertussis (aP)vaccine. However, observational and population-level studies showed that introducing at least a single dose of whole-cell pertussis (wP) vaccine within the routine immunization schedule is associated with better disease protection and a longer duration of immunity. On the other hand, wP vaccine is more reactogenic and associated with higher adverse events. Therefore, the selection of vaccine should be weighed against the effectiveness, reactogenicity, and cost-effectiveness. Due to its safety profile, aP vaccine can be offered to wider population groups. Booster adolescent and pregnant immunization programs have been implemented globally to control outbreaks and protect vulnerable infants. Due to the variable effectiveness performance of both vaccines, different countries adopted distinctive immunization programs. Determining the right vaccination approach depends on financial consideration, immunization program infrastructure, adverse event monitoring, and pertussis surveillance in the community.

Whooping cough complicating pulmonary hypertension in pregnancy

We report a case of a previously fit woman who presented at 26 weeks into her fourth pregnancy with a dry cough. Following a nasopharyngeal swab, she was diagnosed with a pertussis infection, and treated with antibiotics. A chest X-ray showed right atrial dilatation and an echocardiogram was scheduled outpatient. However, after re-presenting with worsening cough and dyspnoea, an inpatient echocardiogram was performed which suggested elevated pulmonary pressures with significant tricuspid regurgitation, as confirmed by subsequent cardiac catheterisation. She had an elective caesarean section at 34 weeks and underwent repeat right heart catheterisation which revealed persistent, and likely pre-existing, pulmonary arterial hypertension. This case highlights the importance of thorough assessment of non-obstetric symptoms in pregnancy in formulating alternative differentials, even after a diagnosis has been made, to prevent potentially life-threatening conditions from being missed. It also shows that although often associated, respiratory and cardiac causes may coexist separately.

Effect of Macrolides and β-lactams on Clearance of Bordetella pertussis in the Nasopharynx in Children With Whooping Cough

OBJECTIVE

The purpose of the current study is to investigate the bactericidal effect of macrolides and β-lactams on Bordetella pertussis (B. pertussis) in the nasopharynx and provide guidance for treating macrolides-resistant B. pertussis infections.

METHODS

Patients with whooping cough was diagnosed by culture of nasopharynx swabs between January 2016 to December 2018. B. pertussis was identified using specific antisera against pertussis and parapertussis. Drug susceptibility test was carried out using the E-test method. The clearance of B. pertussis in nasopharynx at 7 and 14 days into and posttreatment with macrolides, and β-lactams was compared.

RESULTS

A total of 125 B. pertussis samples were collected from patients who received single antibiotic treatment. Among those isolates, 62.4% (78/125) had high resistance with minimum inhibitory concentrations greater than 256 mg/L for erythromycin and azithromycin. The MIC90 of piperacillin, cefoperazone-sulbactam, meropenem, ampicillin, ceftriaxone, ceftazidime and trimethoprim-sulfamethoxazole for these isolates was <0.016, 0.094, 0.094, 0.19, 0.19, 0.25 and 0.75 mg/L, respectively. The clearance rate with β-lactams treatment (68.8%, 44/64) was significantly higher than that with macrolides treatment at 14 days posttreatment (50.8%, 31/61) (χ2 = 4.18, P = 0.04). Macrolides had a better clearance rate at 7 days posttreatment than β-lactams (χ2 = 4.49, P = 0.03) for macrolides-sensitive isolates and a worse clearance rate for macrolides-resistant isolates.

CONCLUSION

B. pertussis isolates had a high-resistant rate for macrolides in our study. Macrolides are the first choice for treating pertussis caused by macrolides-sensitive strains, and some β-lactams such as piperacillin should be considered as alternative antibiotics for treatment of macrolides-resistant B. pertussis infection.

[Malignant pertussis in a three-week-old girl]

Whooping cough is an infectious disease caused by Bordetella pertussis. Particularly children under the age of six months can be severely affected by the infection. Severe leukocytosis may lead to thrombosis and pulmonary hypertension and eventually circulatory failure and death. This a case report of a three-week-old girl with malignant pertussis, who due to respiratory insufficiency was mechanically ventilated, and her severe leucocytosis was treated with exchange blood transfusion. Whooping cough may partially be prevented with efficient vaccination programmes.

Effects of Early Administration of Macrolides on Whooping Cough in Adolescents and Adults: A Single-center Retrospective Cohort Study

Objective This study aimed to elucidate the effects of early macrolide administration on genetically confirmed pertussis-induced cough in adolescents and adults. Methods This single-center, retrospective cohort study examined the effects of the early administration of macrolides and antitussive agents on cough secondary to pertussis. We divided the patients into two groups based on the median duration from the beginning of the cough to the initiation of macrolide administration: early macrolide administration group (EMAG) and non-early macrolide administration group (NEMAG). The clinical improvement of cough was defined as maintaining a cough awareness score of ≤3 points for 3 consecutive days. Patients The medical records of 40 patients diagnosed with pertussis (≥12 years old) who were able to maintain a cough diary and received no other antibiotics aside from macrolides were included in the study. A diagnosis of pertussis was made using the loop-mediated isothermal amplification (LAMP) test. Results The EMAG (24 patients) showed a significantly shorter total cough period than the NEMAG [16 patients; 20.0 (95% confidence interval (CI), 16-28) vs. 30.5 (95% CI, 27-40) days; log-rank test, p=0.002]. There was no significant difference in the post-administration cough periods between the EMAG and NEMAG [11.0 (95% CI, 7-19) vs. 13.0 (95% CI, 5-23) days; log-rank test, p=0.232]. Antitussive agents did not affect the cough. Conclusion The early administration of macrolides, but not antitussive agents, is effective for treating pertussis. Therefore, macrolides should be administered as soon as possible for this disease.

Azithromycin to Prevent Pertussis in Household Contacts, Catalonia and Navarre, Spain, 2012-2013

We retrospectively assessed the effectiveness of azithromycin in preventing transmission of pertussis to a patient's household contacts. We also considered the duration between symptom onset in the primary patient and azithromycin administration. We categorized contacts into 4 groups: those treated within <7 days, 8-14 days, 15-21 days, and >21 days after illness onset in the primary patient. We studied 476 primary index patients and their 1,975 household contacts, of whom 4.5% were later identified as having pertussis. When contacts started chemoprophylaxis within <21 days after the primary patient's symptom onset, the treatment was 43.9% effective. Chemoprophylaxis started >14 days after primary patient's symptom onset was less effective. We recommend that contacts of persons with pertussis begin chemoprophylaxis within <14 days after primary patient's symptom onset.

Antibiotic Use Associated with Confirmed Influenza, Pertussis, and Nontyphoidal Salmonella Infections

Purpose: Antibiotics are not the recommended treatment for uncomplicated influenza or nontyphoidal salmonella infections, whereas they are for current pertussis infection. We investigated adherence to these recommendations in a population of older community-dwelling adults. Methods: Population-based prospective cohort study of Australian adults 45 years of age and older followed by record-linkage to laboratory-confirmed influenza, pertussis, and nontyphoidal salmonella notifications, hospitalization records, and antibiotic dispensing data from January 1, 2009 to December 31, 2015. Proportions of those with infections who were prescribed antibiotics were estimated, and characteristics associated with antibiotic prescribing were examined. Results: There were 1,056 influenza, 151 pertussis, and 334 nontyphoidal salmonella cases in the cohort eligible for analysis. Antibiotics were dispensed in 56.2% (594/1,056) of influenza, 78.8% (119/151) of pertussis, and 39.5% (132/334) of nontyphoidal salmonella cases within the ±10-day window around the infection onset date. The likelihood of antibiotic dispensing did not differ according to most participant characteristics examined, including whether cases had an associated hospitalization, their age, and recorded comorbidities. Macrolides were the predominant class of antibiotics dispensed for pertussis (79%), whereas both beta-lactams (36.3%) and macrolides (35.4%) were used for cases of influenza. There was no dominant antibiotic class dispensed among those with nontyphoidal salmonella. Conclusions: Given concerns regarding increasing antibiotic resistance, the high proportion of adults with influenza and nontyphoidal salmonella cases dispensed antibiotics indicate the need for further strengthening of antimicrobial stewardship by raising education and awareness of guidelines for managing these infections.

Analysis of social and medical portrait of children with pertussis, meningococcal infectious, scarlet fever and estimation of their assigned pharmacotherapy

OBJECTIVE

Introduction: The level of childhood bacterial diseases incidence does not have a downward trend. The aim: Conduction of a sociological analysis of medical cards for children with pertussis, meningococcal infection (MI), scarlet fever, and evaluation of consumed pharmacotherapy according to real clinical practice in Ukraine.

PATIENTS AND METHODS

Materials and methods: 1215 medical cards of inpatients; methods: sociological - document analysis, retrospective frequency.

RESULTS

Results: Among the cards of children with pertussis: 50.2% - female, 49.8%- male; by age children up to 1 year (49.3%) were prevailed. In 79.6% incidence - medium-hard form pertussis, 42.2% with complications. Among patients with MI by sex there were: 50.5 % - boys and 49.5% - girls; by age - children aged 1-4 (40.2%); the structure of generalized forms of MI: 40.2% - meningococcemia, 11.4% - meningitis, 48.4% - combination. Scarlet fever was more frequently: boys (56.4%), children aged 5-9 (44.7%), urban residents (79.7%); it was 93.4% of a medium-hard form. Most of medicines were prescribed to children with MI - 15.8 trade names per 1 person, it was prescribed 191 INN, most often - Sodium chloride (90.0%), Ascorbic acid (68.5%), Ceftriaxone (65.8%); patients with pertussis - 11.2, 196 INN (Chlorpromazine (69.1%), Dexamethasone (53.2%), Butamirate (51.8%)); scarlet fever - 9.3 medicines, 114 INN (local action Comb drug for throat diseases treatment (94.4%), Ceftriaxone (48.7%), Metamizole sodium (38.1%)).

CONCLUSION

Conclusions: Frequency analysis data of consumed pharmacotherapy in real pediatric practice in Ukraine shows the need for its further optimization in accordance with the principles of evidence-based medicine, the results of research on the socio-demographic characteristics of patients, forms and complications of course of the basic disease.

[Common cold or whooping cough]

By 2017 IVO has examined two cases with serious illnesses in two children under 6 months of age. In one case, the 4-week old child died. Factors that may have affected the treatment may have been lacking knowledge that the disease is present in society and requests to be restrictive with antibiotic treatment. The current disease cases occurred during a period when RS virus was common. In case of suspicion of whooping cough, prophylaxis and treatment should begin early for optimal effect. Prophylactic treatment of infants younger than 6 months should start without waiting for test results if you suspect that the child is exposed to whooping cough infection.

Prevention of pertussis: from clinical trials to Real World Evidence

Pertussis, a highly contagious infective disease caused by Bordetella pertussis, was in the past very common among newborns and children, causing significant medical, social and economic issues burden, also due to frequent need of hospitalization and high mortality. Following the introduction of vaccines against pertussis, the burden of the disease dramatically decreased, although nowadays, this disease it is still the most widespread among the vaccine preventable ones. First vaccine formulations were composed with whole cell antigen of Bordetella pertussis and were followed by formulations with acellular antigens (PT, FHA, PRN, FIM), that showed to have similar efficacy and less reactogenicity. In particular, all the acellular vaccines, regardless the number of antigenic component included, demonstrated good immunogenicity in clinical trials and high effectiveness in real world evidence studies. Nevertheless, in the recent years it has been notified an increasing number of cases of pertussis. The most recent evidence demonstrated that for an effective control and prevention of pertussis it is necessary to strengthen vaccination coverage among the whole population, providing primary vaccination to newborns and booster in infancy, adolescence and adulthood every 10 years. Finally, vaccination of women at the third trimester of every pregnancy is the most effective intervention to protect the newborn from pertussis in his first months of life, before developing a protective response after the primary vaccination.

Large pertussis outbreak in rural Canada: Lessons learned from Haida Gwaii

OBJECTIVE

To present characteristics of and response to a large outbreak of pertussis on Haida Gwaii, BC, in 2014.

DESIGN

Quantitative descriptive review.

SETTING

Haida Gwaii, a remote island archipelago located 100 km off of British Columbia's west coast.

PARTICIPANTS

All patients presenting with symptoms evaluated for pertussis on Haida Gwaii between February and August 2014.

MAIN OUTCOME MEASURES

The primary outcome measures included the demographic characteristics, time course, and morbidity of the outbreak. The secondary outcome measures included the laboratory result reports, the effects on clinician workload, and the treatment and prophylaxis practices. Statistical analysis for significance of pertussis severity and immunization status was performed with a maximum-likelihood framework.

RESULTS

Between February and August 2014, out of 873 clinical encounters, 579 patients were seen for pertussis-related care. Of these, 260 patients were reported to public health for case identification, contact tracing, and follow-up. There were 123 cases of probable and confirmed pertussis, a case rate of 2795 cases per 100 000 population. Of these 123 cases, 91 had a cough of more than 2 weeks' duration. A subset of patients presented with mild symptoms, atypical of pertussis. Nasopharyngeal swabs were collected on 221 occasions, 378 antibiotic prescriptions were written, and 248 prophylactic immunizations were given. The odds ratio that previous immunization protected against the development of classic pertussis was 0.23; however, statistical significance was not reached (P = .112).

CONCLUSION

Pertussis is resurging. Physicians need to remain vigilant for its characteristic symptoms. Clear and standardized criteria for the declaration of an outbreak should be developed. To contain an outbreak, it is crucial to deploy resources commensurate with disease activity while coordinating public health and primary care. More research into why large outbreaks continue to occur, why endemic rates continue to rise, and how these can be most effectively prevented is essential.

Whooping Cough Alleviated by Homeopathic Medicines: A Case Report

Context • Pertussis cough (whooping cough) is distressing due to the intensity and chronicity of its cough. No specific drugs are available that can alleviate the cough's intensity or significantly shorten its duration. Homeopathic medicines are used for a wide variety of medical conditions, including cough. Objective • The study investigated the benefits of homeopathic medicines for whooping cough, to alleviate the cough's intensity and to shorten its duration. Design • The current study was a case series of patients with whooping cough. Setting • The study took place at one of the suburban hospital clinics of the Ann & Robert H. Lurie Children's Hospital of Chicago (Chicago, IL, USA). Participants • Participants were 20 patients aged 21 mo to 20 y, of whom 11 were female and 18 were male, who visited the hospital clinic for treatment of the chronic cough that is characteristic of whooping cough. The details of the cases of 3 representative participants are highlighted in the text. Intervention • The 3 representative patients all received 1 dose weekly of a 30c dilution of homeopathic pertussinum and a 6c dilution of homeopathic Drosera 3 times daily. The homeopathic medicines most often used for the other participants were the same doses of pertussinum and Drosera. Outcome Measures • Verbal feedback from patient or family were obtained at the follow-up visits. Results • The intensity and duration of participant's coughs were alleviated within days to 1 wk in most cases. Conclusions • Homeopathic medicines can alleviate the intensity or reduce the duration of whooping cough, with no adverse effects.

[A CASE OF PERTUSSIS IN ADULT THAT COULD BE DIAGNOSED BY DETECTION OF BORDETELLA PERTUSSIS FROM SPUTUM]

Bordetella pertussis isolation by culture has low detection sensitivity for diagnosing pertussis; the diagnosis is confirmed by measuring serum anti-pertussis toxin (anti-PT) or anti-filamentous hemagglutinin antibody titers, and by genetic testing (polymerase chain reaction/loop-mediated isothermal amplification). Isolation of B. pertussis in adults is difficult, resulting in a delayed diagnosis, as a delayed cough may present ≥3 months after onset. Differentiation from bronchial asthma is also important. We encountered an adult patient in whom B. pertussis was isolated by culture who previously received rituximab for mucosa-associated lymphoid tissue (MALT) lymphoma and steroids for prolonged cough. No elevation of anti-PT antibody titers was observed in the patient.

The Burden of Pertussis Hospitalization in HIV-Exposed and HIV-Unexposed South African Infants

BACKGROUND

 There are limited data on pertussis in African children, including among human immunodeficiency virus (HIV)-exposed infants. We conducted population-based hospital surveillance to determine the incidence and clinical presentation of Bordetella pertussis-associated hospitalization in perinatal HIV-exposed and -unexposed infants.

METHODS

 Children <12 months of age hospitalized with any sign or symptom of respiratory illness (including suspected sepsis or apnea in neonates) were enrolled from 1 January 2015 to 31 December 2015. Detailed clinical and demographic information was recorded and respiratory samples were tested by polymerase chain reaction (PCR).

RESULTS

 The overall B. pertussis PCR positivity was 2.3% (42/1839), of which 86% (n = 36) occurred in infants <3 months of age. Bordetella pertussis was detected in 2.1% (n = 26/1257) of HIV-unexposed and 2.7% (n = 16/599) of HIV-exposed infants. The incidence (per 1000) of B. pertussis-associated hospitalization was 2.9 (95% confidence interval [CI], 1.8-4.5) and 1.9 (95% CI, 1.3-2.6) in HIV-exposed and HIV-unexposed infants, respectively (P = .09). The overall in-hospital case fatality ratio among the cases was 4.8% (2/42), both deaths of which occurred in HIV-exposed infants <3 months of age. Among cases, presence of cough ≥14 days (20.5%) and paroxysmal coughing spells (33.3%) at diagnosis were uncommon. Only 16 (38%) B. pertussis-associated hospitalizations fulfilled the Centers for Diseases Control and Prevention case definition of "definite" pertussis.

CONCLUSIONS

 Bordetella pertussis contributed to a modest proportion of all-cause respiratory illness hospitalization among black-African children, with a trend for higher incidence among HIV-exposed than HIV-unexposed infants. Maternal vaccination of pregnant women should be considered to reduce the burden of pertussis hospitalization in this population.

[Recent progress in clinical research on pertussis]

Pertussis is a highly contagious respiratory disease. Despite the high vaccination coverage, re-emergence of pertussis has been reported in many countries over the past two decades. With the increase in the incidence of pertussis, there has been a shift in the epidemiological features: an increased incidence of pertussis has been noted in older children and adults, who normally lack typical clinical manifestations, and who may be easily missed according to current diagnostic references for pertussis. In order to achieve better prevention and treatment of pertussis, this review article summarized the recent research progress in the epidemiology, clinical features, etiology, diagnosis, treatment, and prevention of pertussis, particularly focusing on the diagnosis of pertussis in older children and adults.

Measures to Control an Outbreak of Pertussis in a Neonatal Intermediate Care Nursery After Exposure to a Healthcare Worker

Background.

Hospitalized premature infants are particularly vulnerable to morbidity and mortality from pertussis. Effective prevention and investigative and control measures are not well described.

Objective.

To identify the source of nosocomial pertussis in a 2-month-old premature infant in a neonatal intermediate care nursery (ICN) and to critically review the investigation and outbreak control measures.

Setting.

An ICN and a neonatal intensive care unit.

Methods.

We queried healthcare workers (HCWs) and family members about cough illness and contacted potentially exposed patients to determine whether they had symptoms of pertussis. Culture and polymerase chain reaction (PCR) testing forBordetella pertussiswere performed by the hospital laboratory with specimens collected from symptomatic patients and HCWs. Levels of pertussis toxin immunoglobulin G antibodies were measured in HCWs with cough of at least 14 days' duration at a public health laboratory. Extensive control measures were instituted.

Results.

Four ICN HCWs met the clinical case definition for presence of pertussis. Serologic test results were positive for 3 of the HCWs. The primary case patient was a 36-year-old HCW with a cough illness of 3-weeks' duration that was accompanied by paroxysms, whoop, posttussive emesis, and pneumothorax. Among the 4 affected HCWs, the duration of cough illness prior to identification of the infant index patient ranged from 11 to 25 days. Outbreak control measures included isolation of the infant case patient, furlough and treatment of symptomatic HCWs, administration of chemoprophylaxis to contacts, and surveillance for additional cases. Seventy-two infant patients and 72 HCWs were exposed and were given antibiotic prophylaxis. One additional case of pertussis, confirmed by PCR and culture, occurred in a resident physician who declined prophylaxis; she had cared for the index patient but had no contact with symptomatic HCWs.

Conclusion.

HCWs or patients may serve as the source of pertussis in nosocomial outbreaks, which can result in substantial morbidity and outlay of resources for control measures. Our review suggested that a diagnosis of pertussis should be an early consideration for HCWs with cough illness. Targeted pertussis immunization of HCWs, employee health policies that provide for testing and furlough of HCWs with prolonged cough, and monitoring of HCWs for compliance with infection control measures could reduce the morbidity and costs associated with pertussis outbreaks. These measures will require evaluation of their effectiveness.

Shattering a myth - Whooping cough susceptible to antibiotics

Bordetella parapertussis is the causative agent of a milder form of pertussis or whooping cough. Little is reported about the antibiotic resistance patterns and mechanism of drug resistance of Bordetella parapertussis. The objective of this study has been to investigate antimicrobial resistance, distribution of integrons and presence of gene cassettes to quinolones (qnr) and sulfonamides (sul) among B. parapertussis strains' isolated from Pakistan. Thirty-five (35) samples were collected from various hospitals of Pakistan from children (median age 3 years) with pertussis-like symptoms, all were tested and confirmed to be B. Parapertussis. Resistance profile of Ampicillin, Cephalexin, Sulphamethoxazole, Chloramphenicol, Ofloxacin, Nalidixic acid, Gentamycin and Erythromycin were investigated through all samples. Majority of the isolates were found to be resistant to the afore-mentioned antibiotics except erythromycin. All isolates were resistant to quinolones phenotypically, but qnr genes were detected in only 25.7% (9/35) of isolates. On the other hand, 71.4% (25/35) isolates were resistant to sulfonamides phenotypically. From these 71% strains showing phenotypical resistance, 96% (24/25) were found to possess sul genes. Only two isolates were carrying class 1 integrons, which also harbored sul gene and qnr gene cassettes. It can be safely concluded that the phenotypic resistance patterns seemed mostly independent of presence of integrons. However, interestingly both integrons harboring strains were resistant to quinolones and sulfonamides and also possessed qnr and sul genes.

Variation in Bordetella pertussis Susceptibility to Erythromycin and Virulence-Related Genotype Changes in China (1970-2014)

OBJECTIVES

To investigate changes in virulence-related genotypes and in the antimicrobial susceptibility of Bordetella pertussis isolates collected from the 1970s to 2014 in the northern part of China.

METHODS

A total of 124 B. pertussis isolates from three periods, the 1970s, 2000-2008, and May 2013-Sept 2014, were typed by multilocus sequence typing (MLST) and tested for antimicrobial susceptibility and virulence-related genes. A fragment of the 23S rRNA gene from each of the 99 isolates from 2013-2014 was amplified and sequenced.

RESULTS

All isolates from 2000-2008 and 2013-2014 were identified as ST2, whereas isolates from the 1970s were ST1. PtxA2/ptxC1/ptxP1/prn1/fim2-1/fim3-1/tcfA2, which was the same as the vaccine strain, was the only type in the 1970s. During the 2000s and 2013-2014, the virulence type ptxA1/ptxC1/ptxP1/prn1/fim2-1/fim3-1/tcfA2 was dominant, with frequencies of 68.4% and 91.9%, respectively. Nine ptxP3 strains, which were more virulent, were detected after 2000. All 124 isolates were susceptible to levofloxacin, sulphamethoxazole/trimethoprim and tetracycline. The isolates from the 1970s and 2000-2008 were susceptible to all tested macrolides, whereas 91.9% of the 2013-2014 isolates were highly resistant (minimal inhibitory concentration, MIC >256 μg/ml). No ptxP3 strain was resistant to macrolides. All erythromycin-resistant strains except for one had the A2047G mutation in the 23S rRNA gene.

CONCLUSIONS

Macrolide resistance of the B. pertussis population has been a serious problem in the northern part of China. Because most of the epidemic clone of the pathogen expresses the same antigen profiles as the vaccine strain, except ptxA, improvements in immunization strategies may prevent the spread of infection and drug resistance.

A field study of household attack rates and the effectiveness of macrolide antibiotics in reducing household transmission of pertussis

Bordetella pertussis (whooping cough) is an endemic, highly contagious bacterial respiratory infection, which is notifiable to Australian state and territory health departments. Between 2008 and 2011 there was a substantial outbreak in New South Wales with an initial increase in cases occurring in North Coast New South Wales from late 2007. During September and October 2011 the North Coast Public Health Unit conducted a household study of secondary attack rates to assess the effectiveness of pertussis vaccination as well as the timely use of antibiotics in preventing household transmission. At the time the study was commenced, notified cases included a large proportion of individuals with a documented history of vaccination against pertussis. We found lower attack rates amongst vaccinated compared with non-vaccinated subjects in all age groups, with the exception of the 5-11 years age group, who were also primarily responsible for the introduction of pertussis into the household. There was an increased risk of pertussis transmission from the household first primary case to contacts when antibiotic treatment was commenced later than 7 days after the onset of symptoms compared with within 7 days. This protective effect of timely antibiotic treatment in relation to transmission highlights the need to control for antibiotic treatment in field studies of pertussis. The benefits of timely diagnosis and use of antibiotics in preventing household transmission underscore the importance of early presentation and diagnosis of pertussis cases, particularly in households with susceptible occupants.

Surveillance for Transmission and antibiotic Adverse Events Among Neonates and Adults Exposed to a Healthcare Worker With Pertussis

Background:

During a hospital obstetric rotation, a medical student demonstrated classic symptoms of pertussis. The diagnosis was confirmed by isolation ofBordetella pertussis. Because this exposure occurred in a high-risk hospital setting, control measures were undertaken to prevent transmission and illness.

Objectives:

To identify secondary cases of pertussis, to determine compliance with chemoprophylaxis recommendations, and to monitor for adverse events associated with chemoprophylaxis following a hospital exposure to pertussis.

Patients:

More than 500 individuals were potentially exposed, including 168 neonates; antimicrobial chemoprophylaxis was administered to 281 individuals. Fifty-eight neonates and 194 adults began azithromycin chemoprophylaxis; 18 neonates and 2 adults began erythromycin chemoprophylaxis.

Methods:

Active surveillance was instituted for (1) secondary cases of pertussis among healthcare coworkers, obstetric patients, their neonates, and labor companions and (2) antibiotic compliance and tolerance.

Results:

No secondary cases of pertussis were confirmed by laboratory tests; however, 26 suspected cases and 5 clinically compatible cases were identified. Antibiotic courses were completed by 95% of the individuals who initiated therapy. Neonates taking azithromycin had statistically significantly less gastrointestinal distress compared with neonates taking erythromycin (12% vs 50%;P= .002); there were no cases of infantile hypertrophic pyloric stenosis.

Conclusions:

Although it was not possible to assess the effectiveness of the antibiotic regimens, the lack of laboratory-confirmed secondary cases suggests control measures were successful. Data from the 58 neonates who received azithromycin suggest it may be well tolerated in this age group.

Nosocomial Pertussis Outbreak Among Adult Patients and Healthcare Workers

We describe a pertussis outbreak among adult patients in a French general hospital following transmission from a healthcare worker. This index case transmitted pertussis to other healthcare workers, who, in turn, contaminated other staff and two immuno-suppressed patients. This raises questions about infection control.

Staying ahead of pertussis

In recent years, pertussis has been on the rise. Here's what you can do to help limit the spread of the disease, and how to promptly diagnose and treat it.

c-di-GMP enhances protective innate immunity in a murine model of pertussis

Innate immunity represents the first line of defense against invading pathogens in the respiratory tract. Innate immune cells such as monocytes, macrophages, dendritic cells, NK cells, and granulocytes contain specific pathogen-recognition molecules which induce the production of cytokines and subsequently activate the adaptive immune response. c-di-GMP is a ubiquitous second messenger that stimulates innate immunity and regulates biofilm formation, motility and virulence in a diverse range of bacterial species with potent immunomodulatory properties. In the present study, c-di-GMP was used to enhance the innate immune response against pertussis, a respiratory infection mainly caused by Bordetella pertussis. Intranasal treatment with c-di-GMP resulted in the induction of robust innate immune responses to infection with B. pertussis characterized by enhanced recruitment of neutrophils, macrophages, natural killer cells and dendritic cells. The immune responses were associated with an earlier and more vigorous expression of Th1-type cytokines, as well as an increase in the induction of nitric oxide in the lungs of treated animals, resulting in significant reduction of bacterial numbers in the lungs of infected mice. These results demonstrate that c-di-GMP is a potent innate immune stimulatory molecule that can be used to enhance protection against bacterial respiratory infections. In addition, our data suggest that priming of the innate immune system by c-di-GMP could further skew the immune response towards a Th1 type phenotype during subsequent infection. Thus, our data suggest that c-di-GMP might be useful as an adjuvant for the next generation of acellular pertussis vaccine to mount a more protective Th1 phenotype immune response, and also in other systems where a Th1 type immune response is required.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

Around 16 million cases of whooping cough (pertussis) occur worldwide each year, mostly in low-income countries. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 1), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, the Database of Abstracts of Reviews of Effects (DARE 2014, Issue 2), accessed from The Cochrane Library, MEDLINE (1950 to 30 January 2014), EMBASE (1980 to 30 January 2014), AMED (1985 to 30 January 2014), CINAHL (1980 to 30 January 2014) and LILACS (30 January 2014). We searched Current Controlled Trials to identify trials in progress.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial for this review in 2009. Two review authors (SB, KW) independently reviewed additional studies identified by the updated searches in 2012 and 2014. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay. 

MAIN RESULTS

We included 12 trials of varying sample sizes (N = 9 to 135), mainly from high-income countries, including a total of 578 participants. Ten trials recruited children (N = 448 participants). Two trials recruited adolescents and adults (N = 130 participants). We considered only three trials to be of high methodological quality (one trial each of diphenhydramine, pertussis immunoglobulin and montelukast). Included studies did not show a statistically significant benefit for any of the interventions. Only six trials, including a total of 196 participants, reported data in sufficient detail for analysis. Diphenhydramine did not change coughing episodes; the mean difference (MD) of coughing spells per 24 hours was 1.9; 95% confidence interval (CI) -4.7 to 8.5 (N = 49 participants from one trial). One trial on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02, N = 47 participants) but no change in hospital stay (MD -0.7 days; 95% CI -3.8 to 2.4, N = 46 participants). Dexamethasone did not show a clear decrease in length of hospital stay (MD -3.5 days; 95% CI -15.3 to 8.4, N = 11 participants from one trial) and salbutamol showed no change in coughing paroxysms per day (MD -0.2; 95% CI -4.1 to 3.7, N = 42 participants from two trials). Only one trial comparing pertussis immunoglobulin versus placebo (N = 47 participants) reported data on adverse events: 4.3% in the treatment group (rash) versus 5.3% in the placebo group (loose stools, pain and swelling at injection site).

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the effectiveness of interventions for the cough in whooping cough. More high-quality trials are needed to assess the effectiveness of potential antitussive treatments in patients with whooping cough.

Whooping cough

The CPD article was relevant to my practice because most upper respiratory tract infections exhibit similar symptoms initially. It is essential to be able to diagnose whooping cough because it is an acute and highly contagious disease.

Pertussis: a reemerging infection

Pertussis, also known as whooping cough, is an acute respiratory tract infection that has increased in incidence in recent years. The initial catarrhal stage presents with nonspecific symptoms of malaise, rhinorrhea, sneezing, lacrimation, and mild cough. During the paroxysmal stage, severe outbreaks of coughing often lead to the classic high-pitched whooping sound patients make when gasping for breath. The paroxysmal stage is followed by the convalescent stage and resolution of symptoms. Complications vary by age, with infants more likely to experience severe complications such as apnea, pneumonia, seizures, or death. In adolescents and adults, complications are the result of chronic cough. The diagnosis depends on clinical signs and laboratory testing. Both culture and polymerase chain reaction testing can be used to confirm the diagnosis; serologic testing is not standardized or routinely recommended. Although antibiotics have not shown clear effectiveness in the treatment of pertussis, they eradicate nasal bacterial carriage and may reduce transmission rates. Macrolide antibiotics such as azithromycin are first-line treatments to prevent transmission; trimethoprim/sulfamethoxazole is an alternative in cases of allergy or intolerance to macrolides. Immunization against pertussis is essential for disease prevention. Current recommendations in the United States consist of administering five doses of the diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine to children before seven years of age, and administering a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) booster between 11 and 18 years of age. Recent efforts have focused on the vaccination of adolescents and adults, with new recommendations for a single dose of the Tdap booster if it has not been previously administered.

Coughing up answers: a community's response to pertussis

Pertussis is a highly contagious but vaccine-preventable disease. In spite of relatively high immunization rates, the number of cases continues to rise. A recent outbreak of pertussis in Alamance County, North Carolina, led to changes in response efforts and improved communication among partners, but it also left public health workers with many unanswered questions.

Resolution of migratory pulmonary infiltrates by moxifloxacin in a patient with dual infection of Mycoplasma pneumoniae and Bordetella pertussis

A 37-year-old Japanese woman, who was not vaccinated against Bordetella pertussis, developed a nocturnal fever with persistent dry cough for more than 2 weeks. A chest radiograph showed poorly-defined nodular opacities in the left lung. Due to the significant rise in serum antibodies for both Mycoplasma pneumoniae and B. pertussis, a diagnosis of dual infection with the organisms was made. Despite the use of susceptible antibiotics, the patient symptoms did not improve and her chest radiograph showed migratory pulmonary infiltrates. However, a quinolone derivative, moxifloxacin, dramatically improved her symptoms and resolved the pulmonary infiltrates shortly after administration. In this case, due to the lymphocyte-stimulatory nature of M. pneumoniae and B. pertussis, an increased immunological response was likely to be involved in the pathogenesis of pneumonia. The immunomodulatory property of moxifloxacin was thought to repress the increased lymphocyte activity, and thus facilitated complete remission of the disease.

[Current status adult pertussis in Japan]

Pertussis has been prevalent among the infants in summer, however, in recent years, it is increasing also in the adult. The epidemiology in 2010 showed pertussis in the adults dominated over 50%. Although the cough in the adults persists for a long time comparing with the infants, the adult pertussis is easy to be overlooked since the symptom is not typical especially in the adults. Therefore, it might be lead to the outbreak in the community. Pertussis is mainly treated by macrolides, such as erythromycin (EM) or clarithromycin (CAM) at present.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

The worldwide incidence of whooping cough (pertussis) has been estimated at 48.5 million cases and nearly 295,000 deaths per year. In low-income countries, the case-fatality rate among infants may be as high as 4%. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta 2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH METHODS

We updated searches of the Cochrane Central Register of Controlled Trials (CENTRAL Issue 2, 2012), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, the Database of Abstracts of Reviews of Effects (DARE Issue 2, 2012) accessed from The Cochrane Library, MEDLINE (1950 to January 2012), EMBASE (1980 to January 2012), AMED (1985 to January 2012), CINAHL (1980 to January 2012) and LILACS (January 2012). We searched Current Controlled Trials to identify trials in progress.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial for this review in 2009. Two review authors (SB, KW) independently reviewed additional studies identified by the updated search in 2012. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay. 

MAIN RESULTS

Ten trials were included of varying sample sizes (N = 9 to 135) from high-income countries. Study quality was generally poor. Included studies did not show a statistically significant benefit for any of the interventions. Only six trials including a total of 196 participants reported data in sufficient detail for analysis. Diphenhydramine did not change coughing episodes; the mean difference (MD) of coughing spells per 24 hours was 1.9; 95% confidence interval (CI) - 4.7 to 8.5. One study on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02) but no change in hospital stay (MD -0.7 days; 95% CI -3.8 to 2.4). Dexamethasone did not show a clear decrease in length of hospital stay (MD -3.5 days; 95% CI -15.3 to 8.4) and salbutamol showed no change in coughing paroxysms per 24 hours (MD -0.2; 95% CI -4.1 to 3.7). Only one trial comparing pertussis immunoglobulin versus placebo reported data on adverse events: 4.3% in the treatment group (rash) versus 5.3% in the placebo group (loose stools, pain and swelling at injection site).

AUTHORS' CONCLUSIONS

There is insufficient evidence to draw conclusions about the effectiveness of interventions for the cough in whooping cough.

Outbreak of pertussis in a university laboratory

OBJECTIVE

Analysis of an outbreak of Bordetella pertussis infection in a university laboratory. To prevent and control the outbreak, we conducted a survey of the laboratory staff and their family members, and we investigated the clinical features of adult pertussis.

PATIENTS AND METHODS

During the outbreak, four out of the 10 laboratory staff and five out of 16 family members had a primary complaint of cough. Seven of nine patients were diagnosed as definitive B. pertussis infection using serology and PCR.

RESULTS

Clinical findings and laboratory data in adult patients with B. pertussis infection demonstrated non-specific cough and normal WBC and lymphocyte count. The patients who received clarithromycin prior to 14 days after clinical onset demonstrated a shorter duration of cough symptoms than patients who received clarithromycin at 14 days or more after clinical onset (duration of cough after administration of clarithromycin: 17.8 ± 6.48 days versus 35.3 ± 5.38 days; duration of total cough after clinical onset: 24.8 ± 6.65 days versus 56.8 ± 6.50 days).

CONCLUSION

The clinical findings of adult pertussis are different from pertussis in children. The efficacy of macrolide therapy clearly differed between the catarrhal phase and paroxysmal phase. Physicians should consider B. pertussis in the differential diagnosis of an outbreak of non-specific respiratory infection even in adult populations.

Nosocomial pertussis infection of infants: still a risk in 2009

The Sydney West Centre for Population Health investigated a confirmed pertussis infection in a health care worker on a maternity ward and identified pertussis infection in 4 neonates cared for by this case. This report describes the public health intervention to identify and prevent further cases. Of the 4 neonates, three were laboratory-confirmed cases and one was diagnosed on clinical grounds alone. All were cared for by the infected worker during only one shift and developed symptoms six to 16 days afterwards. No other possible source of infection was identified. This investigation highlights the need to maintain awareness, particularly amongst staff working with neonates, that pertussis infection can arise despite complete vaccination. Thus it is important to investigate new coughing illnesses and exclude symptomatic staff from contact with neonates until pertussis infection is excluded or effectively treated. The burden on the health system arising from a pertussis infection in a health care worker in a high-risk setting is also described with the hospitalisation of 4 infants, and prophylactic antibiotics given to 73 new mothers, infants and health care workers.

Maternal pertussis is hazardous for a newborn: a case report

Pertussis, or whooping cough, a highly contagious disease caused by Bordetella pertussis, is making a comeback globally and nationally in spite of reasonable vaccination coverage. Worldwide, there have been increasing reports of Bordetella pertussis infection among adolescents and adults, but the peak incidence and highest mortality occur among infants. We report a 19-day-old female infant presenting with progressive respiratory failure. The mother was the only familial contact who complained of mild cough. However, occasional apneic episodes with cyanosis and peripheral lymphocytosis prompted us to examine the presence of Bordetella pertussis, which remains a significant cause of morbidity and mortality in unimmunized infants. Understanding the source of pertussis transmission to infants may provide new approaches to prevent pertussis in the most vulnerable infants. Various potential strategies have been reviewed or recommended in countries with the aim of better protecting infants against pertussis. Public health measures to prevent the disease could be strengthened and booster vaccinations against pertussis considered.

Symptomatic treatment of the cough in whooping cough

BACKGROUND

The worldwide incidence of whooping cough (pertussis) has been estimated at 48.5 million cases and nearly 295,000 deaths per year. In low-income countries, the case-fatality rate among infants may be as high as 4%. Much of the morbidity of whooping cough in children and adults is due to the effects of the paroxysmal cough. Cough treatments proposed include corticosteroids, beta 2-adrenergic agonists, pertussis-specific immunoglobulin, antihistamines and possibly leukotriene receptor antagonists (LTRAs).

OBJECTIVES

To assess the effectiveness and safety of interventions to reduce the severity of paroxysmal cough in whooping cough in children and adults.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register and the Database of Abstracts of Reviews of Effects (DARE); MEDLINE (1950 to March 2009); EMBASE (1980 to March 2009); AMED (1985 to March 2009); CINAHL (1982 to March 2009) and LILACS (March 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of any intervention (excluding antibiotics and vaccines) to suppress the cough in whooping cough.

DATA COLLECTION AND ANALYSIS

Two review authors (SB, MT) independently selected trials, extracted data and assessed the quality of each trial. The primary outcome was frequency of paroxysms of coughing. Secondary outcomes were frequency of vomiting, frequency of whoop, frequency of cyanosis (turning blue), development of serious complications, mortality from any cause, side effects due to medication, admission to hospital and duration of hospital stay.

MAIN RESULTS

Ten trials were included of varying sample sizes (N = 9 to 135) from high-income countries. Study quality was generally poor. Included studies did not show a statistically significant benefit for any of the interventions. Diphenhydramine did not change coughing episodes; the mean difference of coughing spells per 24 hours was 1.9 (95% confidence interval (CI) - 4.7 to 8.5). One study on pertussis immunoglobulin reported a possible mean reduction of -3.1 whoops per 24 hours (95% CI -6.2 to 0.02) but no change in hospital stay (-0.7 days) (95% CI -3.8 to 2.4). Dexamethasone did not show a clear decrease in length of hospital stay (-3.5 days) (95% CI -15.3 to 8.4) and salbutamol showed no change in coughing paroxysms per 24 hours (-0.22) (95% CI -4.13 to 3.69).

AUTHORS' CONCLUSIONS

Insufficient evidence exists to draw conclusions about the effects of interventions for the cough in whooping cough.

Clinical approach to acute cough

Acute cough is among the most common symptoms for which patients seek medical attention. It accounts for millions of days lost from school and work and billions of dollars spent on medical care. Acute cough is defined as cough present for 3 weeks or less. It most often is caused by a viral infection of the upper respiratory tract (“common cold”) or lower respiratory tract (i.e., “acute bronchitis”). The most effective treatment for cough due to the common cold is a combination first-generation antihistamine plus decongestant. Antibiotics are not indicated for most cases of acute cough. Occasionally, acute cough can be a symptom of a life-threatening condition.