Pertussis : Chemoprophylaxis

Availability in Hospital Keningau

• Azithromycin 250mg
• Clarithromycin 250mg
• Erithromycin 400mg
• Bactrim 

High Risk Groups:

• The need for prophylaxis in the following high risk groups is particularly important infants
•  non-immunized children
• immuno-compromised individuals
• pregnant women
• individuals with chronic respiratory illness, including asthmatics

 Treat /give prophylaxis to close contacts of case with the following as a guide:

• If symptomatic people are already beyond their infectious period, which ends 21 day after cough onset, treatment is not of use. However they should be referred for medical evaluation.
• For asymptomatic individual, if their last exposure occurred beyond 21 days, prophylaxis is not needed.

Table 1: Antimicrobial Agents for Treatment and Prophylaxis of Pertussis

Drug	Infant<6months	INFANT ≥6 MONTHS AND CHILDREN	Adults
Erythromycin (stearate)	< 30 days of age: not preferred as it is associated with infantile hypertrophic pyloric stenosis, Use if azithromycin is unavailable. Dosage is 40 – 50 mg/kg per day in 4 divided doses for 14 days. 1 – 5 months of age: 40-50 mg/kg/day divided into 4 doses, for 14 days.	40-50 mg/kg/day in 4 divided doses, for 14 days (maximum 2 g/day)	2 g/day in 4 divided doses, for 14 days.
Erythromycin Ethyl Succinate		80-100 mg/kg/day divided into q8hr or q6hr dosing for 14 days	400 mg four times a day for 14 days for 14 days*
Clarithromycin For those unable to tolerate erythromycin. Not recommended during pregnancy.	Not recommended for use in infants <1 month of age; for infants >1 month of age use child dose.	15 mg/kg/day divided into 2 doses, for 7 days (maximum 1 g/day).	1 g per day in 2 divided doses for a minimum of 7 days.
Azithromycin 5-day course. For those unable to tolerate erythromycin.	Preferred antimicrobial for use in children <1 month of age; 10 mg/kg per day in a single dose for 5 days. for infants >1 months of ag; 10 mg/kg/day in a single dose for 5 days	10 mg/kg/day on the first day, then 5 mg/kg once daily for next 5 days (maximum 500 mg).	500 mg on the first day, then 250 mg once daily for next 5 days.
Trimethoprim- Sulfamethoxazole (Bactrim®, Septra®)	Should not be used for children <2 month of age (risk of kernicterus); for infants >2	TMP 8 mg/ kg per day, SMZ 40 mg/ kg/day in 2 divided doses, for 14 days.	TMP 320 mg per day, SMZ 1600 mg per day in 2 divided doses, for 14 days.

*based on pharmakinetic and product recomendation, an alternative dosing to EES 400mg QID is 800mg BD

Caution

• Macrolides taken by pregnant or breastfeeding mothers have been reported with
• an increased risk of infantile pyloric stenosis. The risk is presumed to be lower for azithromycin than for erythromycin;
• however there have been reports in the literature of pyloric stenosis in infants of women treated in pregnancy with azithromycin. 
• Inform patients to contact their doctor if vomiting or irritability with feeding occurs.

Therapy Rationale

• In a 2007 Cochrane systematic review of antibiotics for pertussis, the authors concluded that although antibiotic therapy for cases was effective in eliminating B. pertussis, it did not alter thesubsequent clinical course of the illness.
• Short term use (azithromycin for 3–5 days; clarithromycin or erythromycin for seven days) was as effective as erythromycin for 10–14 days in eradicating B. pertussis from the nasopharynx and had fewer side effects

References:

1. CASE INVESTIGATION AND OUTBREAK MANAGEMENT FOR HEALTHCARE PERSONNEL: PERTUSSIS 2010
2. https://www.cdc.gov/vaccines/vpd/pertussis/tdap-revac-hcp.html
3. http://www.webmd.com/children/vaccines/dtap-and-tdap-vaccines#1
4. Guidelines for the Public Health Management of Pertussis Public Health Medicine Communicable Disease Group HSE. October 2013
5. Pertussis Antibiotic Recommendations for Treatment and Prophylaxis. Milwaukee Health Dept (2004)
6. Health Professionals Advice: Azithromycin now fully funded. 3 December 2012 
7. National Antibiotic Guideline, 2014