Powerpoint Templates میحرلا نمحرلا الله مسب · Powerpoint Templates Page 13 Infants Short catarrhal period, longer convalescence period Cough,feeding abn, res distress,apnea,cyanosis,

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Bordetella pertussis

http://www.hhmi.princeton.edu/sw/2002/psidelsk/Microlinks.htm

Roxana M.Ghanaie

Ped Infectious Disease

Subspecialist



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Bordetella pertussis Basics

• Aerobic, Gram negative coccobacillus

• Alcaligenaceae Family

• Specific to Humans

• Colonizes the respiratory tract

– Whooping Cough (Pertussis)



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Bordetella pertussis

Jules Bordet

1870-1961

is a bacterium identified in 1900 byJules Bordet and Octave Gengou butisolated only in 1906 because of thedevelopment of a medium containingpotatoes extract and rabbit blood



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Why speaking about Pertussis?

• Global 2018:

• 89'000 estimated deaths (2008)

• 86% estimated DTP3 coverage

• 151'074 reported cases

• Iran pertussis incidence 2010 : 0.5/

100000

• DTP3 coverage more than 95%



Page 6Source: WHO/IVB

pneumococcal (28%)

measles (21%)

rotavirus (16%)

Hib (15%)pertussis (11%)

tetanus (8%)

76% 24%

yellow fever (1%)

diphtheria (<1%)

polio (< 1%){

Estimated annual childhood deaths,

2002

10.5 million deaths under 5 years of age

1.4 million from diseases where vaccination is currently available

1.1 million from diseases where vaccines will be available by 2008

Meningococcal (< 1%)



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Classic Manifestation

• The incubation period of pertussis is usually

7 to 10 days, with a range of 4 to 21 days.

• “The cough of 100 days”,China,The

clinical course of illness is divided into

three stages.( age, vaccination, waning)

• The catarrhal stage is characterized by the

onset of runny nose, sneezing, low-grade

fever, and a mild cough. Cough gradually

becomes more severe (1-2 weeks)



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• The paroxysmal stage is characterized

by coughing fits (paroxysms), which may

be followed by a high-pitched inspiratory

whoop, vomiting, and/or apnea. (1-6

weeks), but may continue for 10 weeks

• The convalescent stage is characterized

by fewer paroxysmal coughing episodes

and usually disappears in 2-3 weeks, but

may continue for months.

Classic Manifestation



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Complications

• Losing weight, pneumonia, otitis, seizure,

encephalopathy, apnea

• Epistaxia, melena, subdural hematoma,

inguinal hernia, rectal prolapse,



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Infants

The severity of pertussis and the rapidity

of its progression in young infants is

effected by a number of factors such as:

the presence of transplacentally

acquired maternal antibodies to B.pertussis,

the infectious dose of bacteria that the

infant receives,

co-infection with respiratory viruses and

perhaps genetic factors related to the

pathogen or the infant.



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Infants

Short catarrhal period, longer convalescence period

Cough,feeding abn, res distress,apnea,cyanosis,

bradycardia, whoop uncommon,

paroxysms and this may lead to apnea, gasp,

hypoxia and occasionally seizures

Initially the chest is clear on auscultation but in fatal

cases B. pertussis pneumonia is always present.

Co-infection with respiratory viruses (particularly

RSV and adenoviruses) can confuse the diagnoses

because of a bronchiolitic picture (air trapping and

expiratory distress).



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Pertussis Among Adolescents and

Adults

• Accounts for up to 7-30% of cough illnesses per year

• Disease often milder than in infants and children

• Infection may be asymptomatic, or may present as classic pertussis

• Cough may last 21 d, st. paroxysmal



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Clinical manifestation in immunized

• Mild , unrecognized cough

• Prolonged cough

• Persons with mild disease may transmit the infection

• Older persons often source of infection for children

• Adults: sleep disturbances, syncope,

incontinence, rib Fx,pneumonia



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Definition:

Clinical Case Definition of Pertussis • In the absence of a more likely diagnosis a cough illness

lasting ≥2 weeks with one of the following symptoms:

• Paroxysms of coughing, OR

• Inspiratory “whoop,” OR

• Posttussive vomiting, OR

• Apnea (with or without cyanosis) (FOR INFANTS AGED

< 1 YEAR ONLY)

• OR

• clinician suspicion of pertussis



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Laboratory Criteria for Pertussis Diagnosis

• Isolation of Bordetella pertussis from a clinical specimen (culture positive), or

• Positive polymerase chain reaction (PCR)

assay for B. pertussis DNA.

Note: Serological testing for B. pertussis is not standardized ( 11 years old, 1 year after vaccination)

• Serology and DFA results should not be relied on as a criterion for laboratory confirmation of pertussis.

Definition:



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Pertussis Case Classification

• Confirmed:

– a. A positive culture for B. pertussis and an acute cough illness of any duration, or

– b. Meets the clinical case definition and is confirmed

by PCR, or

– c. Meets the clinical definition and is epidemiologically

linked directly to a case confirmed by either culture or

PCR. ( close contact in 3 weeks after cough begins)

• Probable: A case that meets the clinical case definition,

is not laboratory confirmed, and is not epidemiologically

linked to a laboratory-confirmed case; also includes

cases meeting the outbreak case definition



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Outbreaks

• Outbreak: Two or more cases involving two or more

households clustered in time (e.g., occurring within 42 days of each other) and either epi-linked or sharing a common space (e.g., in one building) where transmission is suspected to have occurred (e.g. a school).

• One case in an outbreak must be lab confirmed (PCR positive and meets case definition, or culture positive). In an outbreak setting, a case may be defined as an acute cough illness lasting ≥ 2 weeks without other symptoms.



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Transmission

• Very Contagious, 80% secondary attack rate among susceptible persons( even immunized)

• Transmission occurs via respiratory droplets, direct contact with respiratory secretions from infected individuals

• Parents are a common source of B. pertussisinfections for infants,

• grandparents, uncles ,

Aunts also provide another

potential source of infection



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Transmission

Pertussis Infectious Period:

• Most infectious during the catarrhal (early) stage.

• Infectious during the first 21 days of cough if not

treated with appropriate antibiotic.

• No longer infectious after 5 days of treatment with

appropriate antibiotic

• Length of communicability: age, immunization status,

appropirate antibiotic therapy

• Isolation: standard, droplet



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B. parapertussis

• B. parapertussis infection in humans can cause unrecognized infection, mild

pertussis, or classic pertussis

• B. bronchisepica



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DD prolonged cough

• Adenovirus

• Para influenza

• Influenza A,B

• M.pneumonia

• RSV

• C.trachomatis

• C. pneumonia



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• Laboratory confirmation of pertussis is

difficult and delayed. Therefore, clinicians

need to make the diagnosis of

• pertussis presumptively in patients with a

history of intense paroxysmal or chronic

coughing with or without whooping, color

changes, posttussive vomiting, incomplete

or absent pertussis vaccination, and

finding of lymphocytosis on laboratory

examination.

DD



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DD prolonged cough

• spasmodic attacks of coughing may be

observed in children with:

• bronchiolitis, bacterial pneumonia, cystic

fibrosis, or tuberculosis. Afebrile

Pneumonia Syndrome

• The cough associated with: sinusitis,

airway foreign body



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CXR Indications

• 1/ <1y

• 2/ toxic

• 3/ progressive cough>3 w

• 4/ res distress

• 5/ probable underlying dis( CF, CHD,forign

body, Hilar LAD)



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Chest Xray

• Most common : Normal

• Shaggy heart( central airway not periph)

• Hyperinflation, hyper lucent lung

• Micro athelectasia

• Secondary bac. Pneumonia

• Bronchiolitis oblitrans( adeno, influ,

measles, pertussis)

• pneumothorax



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Management:

• The desired outcomes are:observing the severity of cough

limiting the number of paroxysms,

providing assistance when necessary,

maximizing nutrition, rest, and recovery,

follow the course of disease

prevent/treat complications



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• Admitt:

1- all infants<3 m despite severity & all 3-6 m except

the attacks are mild as observed by physician

2- with complications(intractable nausea and

vomiting, failure to thrive,seizures, encephalopathy,

or for patients with sustained hypoxemia during

coughing paroxysms who require supplemental

oxygen,) hx of prematurity in infant, with underlying

cardiac, pul, neuromuscular dis



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Management

• For the hospitalized patient, in addition to

standard precautions, droplet precautions

are recommended

• Monitor heart rate, respiratory rate, and

oxygen saturation of hospitalized patients

continuously,especially in relation to

coughing paroxysms. Coughing, feeding,

vomiting, and weight changes should be

recorded.



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Management:

• Oxygen,suction,hydration, nutrition

• Patients who are severely ill may require treatment in

an ICU.

• Investigate all probable, pertussis reports. Evaluate

whether reported case’s symptoms are compatible

with pertussis

• Recommend antibiotics for the index case (first case

reported to public health authorities), all household

and close contacts. Antibiotic inspite of age,

immunization Hx



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Report & find contacts

• Only confirmed and probable cases are

reported.

• Recommend DTaP/Tdap vaccination

according to appropriate age for exposed

children, adolescents and adults.

• Exposed children < 7 years of age whose last

DTP( 4th dose) was more than 3 years ago

should be vaccinated.( more than 6m after 3rd

dose)



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• Evaluate close contacts for pertussis

symptoms, and when possible collect

specimens for lab testing from

symptomatic persons

• Vaccine after discharge:

If documented disease, do not need additional doses of pertussis vaccine

Satisfactory documentation of disease:

recovery of B. pertussis on culture, OR typical symptoms and clinical course when epidemiologically linked to a culture- proven case

Report & find contacts



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Treatment (cont)

During catarrhal stage ameliorate disease

After cough establishment, does not

generally lessen duration; protect others

Limited benefit if begun >21 days after

onset/exposure

Exception: high risk cases/contacts -

treat up to 6 weeks



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Treatment

• Antibiotic therapy

– Erythromycin

– Azithromycin

– Clarithromycin

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http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/graphics/eryt2.jpg


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Treatment

Erythromycin

For children: 40-50 mg/kg/d in 4 divided doses;10-14 days

• For adults: 1 to 2 g/day given every 6 h



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Treatment

Azithromycin

• for children: at 10 mg/kg on day 1 and 5

mg/kg on days 2 to 5 as a single dose

for 5 days

• 10-12 mg/kg/d PO in 1 dose for a total of 5

days. ( < 6m)

• for adults: 500 mg on day 1 and 250 mg

on days2 to 5



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Treatment

Clarithromycin

• for children: at 15 to 20 mg/kg/day in two

divided doses for 7 days

• for adults: 1 g/day in two doses for 7 days



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Treatments

Trimethoprim(T)/Sulfamethoxazole (S)

8mg/kg T + 40 mg/kg S/d in 2

divided doses; 14 days

• Erythromycin and clarithromycin are not

recommended in infants younger than 4-6 w

because their use has been associated with

increased risk for infantile hypertrophic pyloric

stenosis (IHPS).

• Resistant to macrolid: rare

• Cephalosporine, PN not effective



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Treatment

• Humans infected with B. parapertussis or B. holmesii

• macrolide therapy indicated above.

• In contrast, however, B. bronchiseptica is usually resistant to Erythromycin Most

sensitive to aminoglycosides, extended-

spectrum third-generation penicillins,

tetracyclines, quinolones, and trimethoprim-

sulfamethoxazole.



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Treatment

• It has been observed in numerous small

studies that pertussis infant deaths relate

directly to the degree of leukocytosis

• double volume exchange transfusion, to

lower the white blood cell count



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Treatment

• Pertussis-specific immune globulin is an

investigational product that may be

effective in decreasing paroxysms of

cough but requires further evaluation.

• The use of corticosteroids, albuterol, and

other beta2-adrenergic agents for the

treatment of pertussis is not

supported by controlled, prospective data



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Exclusions from

work/school

Symptomatic: first 5 days of treatment

Symptomatic, refuses treatment:

exclude for 21 days from onset of

symptoms

Asymptomatic exposure: no exclusion



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Complications in Infants

• Pneumonia( in 22% infants)

• Seizures( in 2% infants)

• Encephalopathy( less than 0.5%

infants)

• FTT,Death 0.3%( 1% in less than 2 m-

old)

• SIDS( ???)



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Prognosis

• Prognosis for full recovery is excellent; however, patients

with comorbid conditions as previously described have a

higher risk of morbidity and mortality

• Leukocytosis, particularly WBC counts of more than

100,000, has been associated with fatalities from

pertussis.

• Another study showed that WBC counts of more than

55, 000 and pertussis complicated by pneumonia were

independent predictors of fatal outcome in a multivariate

model.



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Use a narrow definition of

close contact

Close contacts:

• Household contacts;

• Other persons having direct prolonged exposure

to the case while case was contagious and was

coughing or sneezing.

1. Direct face-to-face contact for an undefined time

period with an infectious pertussis case (case

coughing < 21 days and has not completed 5 days of

appropriate antibiotic treatment).



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Use a narrow definition of

close contact

2. . Shared confined space in close proximity for a

prolonged period of time, such as ≥ 1 hour, with an

infectious pertussis case. For example, riding in a car

with a pertussis case.

3. Direct contact with respiratory, oral, or nasal

secretions from an infectious pertussis case (e.g., an

explosive cough or sneeze in the face, sharing food, sharing eating

utensils, kissing, mouth-to-mouth resuscitation, or performing a full

medical exam including examination of the nose and throat without

wearing a mask). Summary of Pertussis Investigation and Control Guidelines Colorado Department of Public Health and Environment

Communicable Disease Epidemiology Program



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Exposed

• Household, close contacts, health care worker:

• Check immunization, initiate, complete

• Chemopx for all contacts regardless age,

immunization

• If start later than 21 d after exposure, give only to

highrisk: young infant, pregnant, care taker of infants

• Monitor for 21 d after last contact, for symptoms

• Evalute symptomatic exposed persons and exclude

from public setting and report confirmed, probable

cases



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QUESTIONS?



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Diphtheria



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Management

1/ Critical care needs

2/ Neutrilize toxin

3/ Eradicate C. diphtheria

4/ Complications

• Mechanical ventilation (combination of

airway obstruction by the diphtheritic

membrane and peripharyngeal edema )



Page 55

Anti toxin

• Specific antitoxin is the mainstay of

therapy and should be administered on the

basis of clinical diagnosis

• neutralizes free toxin only.

• Efficacy diminishes with elapsing time

after the onset of mucocutaneous

symptoms.

• Only an equine preparation is available



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Anti toxin

• Antitoxin is administered once at an

empiric dose based on the degree of

toxicity, site and size of the membrane,

and duration of illness.

• Most authorities prefer the intravenous

route, with infusion over 30-60 minutes.



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Anti toxin

• Antitoxin is probably of no value for local

manifestations of cutaneous diphtheria,

but its use is prudent because toxic

sequelae can occur.

• Commercially available IVIG ,contain

antibodies to diphtheria toxin; is not

proved or approved

• Antitoxin is not recommended for

asymptomatic carriers.



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Antitoxin

دت محل و اندازه غشای دیفتری، شدوز تزریقی ضد سم بر اساس •

:تعیین می شوداثرات سم و مدت زمان شروع بیماری

ط تا وجود لنفادنوپاتی گردنی منتشر و نرم نشاندهنده جذب متوس•

شدید سم است

48درگیری حلق و یا حنجره بمدت کمتر و یا مساوی •

واحد40000-20000ساعت،

واحد60000-40000درگیری نازو فارنژیال •

روز و یا بیشتر و یا تورم 3بیماری شدید یا گسترده یا بمدت •

واحد120000-80000شدید گردن

40000-20000در دیفتری پوستی معموال اثر ندارد ولی بعضی •

واحد را توصیه می کنند



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Antimicrobial

• Eradication, prevent transmission, halt toxin production

• C diphtheriae is usually susceptible to various agents in vitro, including penicillin,erythromycin, clindamycin,

rifampin, and tetracycline.

• Penicillin and erythromycin are only recommended for

treatment.

• Erythromycin is marginally superior to penicillin for

eradication of nasopharyngeal infection.

• Resistance to erythromycin is common in closed

populations if the drug has been used broadly



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Antimicrobial

-40) روز14بمدت اریترو مایسین خوراکی و یا تزریقی •

(گرم در روز2بازای هر کیلوگرم وزن، حداثر 50

واحد بازای هر 100-150000-تزریقی Gپنی سیلین •

داخل وریدی برای مدت ( دوز4کیلوگرم وزن منقطع در

روز14

25-50000) تزریقی عضالنی پروکایین Gپنی سیلین •

واحد بازای هر کیلوگرم وزن بدن روزانه در دو دوز

روز14بمدت ( منقسم



Page 61

Antimicrobial

• Antibiotic therapy is not a substitute for

antitoxin therapy.

• Elimination of the organism should be

documented by at least 2 successive

cultures from the nose and throat (or skin)

obtained 24 h apart after completion of

therapy.

• Treatment with erythromycin is repeated if

culture results remain positive



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Vaccine

• Diseases dose not produce immunity,

vaccinate the patient in convalescent

period



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Surgical Care

• Otolaryngeal assessment is needed in

patients with severe respiratory or

neurologic complications or as part of

critical care.



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Consultation

Cardiologist:

Elevation of serum AOTclosely parallels the

severity of myonecrosis.

arise during the first 10 days of illness or may be

delayed until 2-3 weeks after

In electrocardiographic tracings, a prolonged PR

interval, changes in the ST-T wave, and single

or progressive cardiac dysrhythmias can occur,

such as first-degree, second-degree, and third-

degree heart block, atrioventricular dissociation,

and ventricular tachycardia.

Toxic cardiomyopathy and myocarditis



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• Neurologist:

• parallel the extent of primary infection and

are multiphasic in onset.

• Hypesthesia and local paralysis of the soft

palate

• Weakness of the posterior pharyngeal,

laryngeal, and facial nerves , causing a

nasal tone in the voice, difficulty

inswallowing, and risk of death from

aspiration.



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Neuropathy

• Cranial neuropathies characteristically occur in

the fifth week and lead to oculomotor and ciliary

paralysis, which manifest as strabismus, blurred

vision, or difficulty with accommodation.

• Symmetric polyneuropathy begins within 10

days to 3 months after oropharyngeal infection,

motor function deficit with diminished deep

tendon reflexes. DD polyneuropathy of Landry-

Guillain-Barré syndrome.

• Paralysis of the diaphragm can ensue.



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Close contact

• Promptly identify close contacts of patients

in whom diphtheria is suspected. in the

household and other persons with a

history of habitual close contact with the

patient.



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Close contact

• For close contacts, irrespective of their

immunization status, the following measures

should be taken:

• Surveillance for 7 days for evidence of disease

• Culture for C diphtheriae

• Antimicrobial prophylaxis with oral erythromycin

(40-50 mg/kg/d for 7 d; not to exceed 2 g/d) or a

single intramuscular injection of penicillin G

benzathine (600,000 U for children who weigh <

30 kg and 1.2 million U for children weighing >30

kg and adults)



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Carrier

• Obtain repeated pharyngeal cultures from contacts

proven to be carriers at a minimum of 2 weeks after

completion of therapy.

• Asymptomatic, previously immunized, close contacts

should receive a booster dose of a preparation

containing diphtheria toxoid (DTaP, DT, Tdap, or Td,

depending on age) if they have not received a booster

• dose of diphtheria toxoid within 5 years. Immunize

children in need of the fourth dose.

Contacts who cannot be kept under surveillance should

receive benzathine penicillin G (not erythromycin),

• and a dose of , DT, or Td (administered if the patient has

not received a booster injection within 1 year)



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Mortality/Morbidity

• Death due to mechanical airway

obstruction or cardiac involvement with

circulatory collapse

• In at least 10% of patients with respiratory

tract diphtheria



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Mortality/Morbidity

Prognosis depends on:

• The virulence of the organism (with the gravis

strain usually accounting for the most

severedisease),

• The age and immunization status of the

patient,

• The site of involvement,

• The speed with which antitoxin is administered



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Mortality/Morbidity

• Airway obstruction by the diphtheritic

membrane and peripharyngeal edema

combine to pose a risk of death in patients

with diphtheria.



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Mortality/Morbidity

• For patients in whom disease is

recognized on day 1 and therapy is

promptly initiated, the mortality rate is

approximately 1%.

• If appropriate treatment is withheld until

day 4, the mortality rate rises to 20%



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Mortality/Morbidity

• Toxic cardiopathy occurs in approximately

10-25% of patients with diphtheria and is

responsible for 50-60% of deaths.

• Neurologic complications parallel the

extent of primary infection and are

multiphasic in onset.



Page 75

QUESTIONS?


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Powerpoint Templates میحرلا نمحرلا الله مسب · Powerpoint Templates Page 13 Infants Short catarrhal period, longer convalescence period Cough,feeding abn, res distress,apnea,cyanosis,