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The Centers for Disease Control and Prevention (CDC) has released guidelines on antimicrobial agents for the treatment and postexposure prophylaxis of pertussis. The full report was published in the December 9, 2005, issue of Morbidity and Mortality Weekly Report and is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm.
Recommendations
The use of antibiotics and antimicrobial agents for postexposure prophylaxis eliminates Bordetella pertussis from the nasopharynx of infected persons. Early macrolide administration can reduce the duration and severity of symptoms and shorten the communicability period. Postexposure chemoprophylaxis can be given to asymptomatic contacts to prevent secondary cases, but symptomatic contacts should be treated as if they have pertussis.

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TREATMENT
Erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax) are preferred for the treatment of pertussis in persons one month and older. In thoses younger than one month, the use of erythromycin and clarithromycin is not recommended, and azithromycin is preferred. For patients two months and older, an alternative agent, trimethoprim/sulfamethoxazole (TMP/SMX [Bactrim, Septra]), is available.
When choosing an antimicrobial for treatment or prophylaxis, the following factors should be taken into account: effectiveness, safety, tolerability, ease of adherence, and cost. Azithromycin and clarithromycin are as effective as erythromycin for treatment of pertussis in patients six months and older. They also are better tolerated and are associated with fewer and milder side effects than erythromycin. However, erythromycin is available in generic form and is less expensive.
POSTEXPOSURE PROPHYLAXIS
If there is no contraindication, a macrolide can be given as prophylaxis for persons who are in close contact with a patient who has pertussis. Before making a decision about postexposure chemoprophylaxis, the following factors should be evaluated: infectiousness, degree of exposure, potential consequences of severe pertussis in the contact, and possibilities for secondary exposure of persons at high risk (e.g., those younger than 12 months). Benefits should be weighed against the potential side effects of the drug.
Giving postexposure prophylaxis to asymptomatic household contacts within 21 days of the original patient’s cough onset can prevent symptomatic infection. Symptomatic household members should be treated as if they have pertussis. Postexposure prophylaxis should be administered in infants younger than 12 months or women in the third trimester of pregnancy, because they are at risk for severe and possibly deadly complications. The recommended antimicrobial agents and dosages for postexposure prophylaxis are the same as those for the treatment of pertussis (Table 1).
SPECIAL CONSIDERATIONS
The U.S. Food and Drug Administration has not approved any macrolide for use in infants younger than six months. Information regarding the safety and effectiveness of azithromycin and clarithromycin use in this age group is limited.
Small clinical studies propose that azithromycin and clarithromycin are similarly effective in patients one to five months of age and in older infants and children. These limited trials support the use of azithromycin and clarithromycin as first-line agents in infants one to five months of age. This is because of their in vitro effectiveness against B. pertussis, their more convenient dosing, and their recognized safety and effectiveness in older children and adults. However, it should be noted that untreated infants with pertussis remain culture-positive for a longer duration than older children and adults.
SAFETY
A macrolide is contraindicated if there is a history of hypersensitivity. The common side effects of oral macrolides are gastrointestinal (e.g., nausea, vomiting, abdominal pain and cramps, diarrhea, anorexia) and rashes. Side effects are more common and severe with erythromycin therapy.
Specific Antimicrobial Agents AZITHROMYCIN
Azithromycin is administered as a single daily dose, and it is classified as a Pregnancy Category B drug. Because they reduce absorption of azithromycin, antacids containing aluminum or magnesium should not be used by patients taking azithromycin. Physicians should be cautious about prescribing to patients with impaired hepatic function, and patients should be monitored if they also use agents that are metabolized by the cytochrome P450 enzyme system or other drugs for which pharmacokinetics change (e.g., digoxin, triazolam [Halcion], or ergot alkaloids). Possible side effects of azithromycin use include abdominal discomfort or pain, diarrhea, nausea, vomiting, headache, and dizziness.
ERYTHROMYCIN
A 14-day course of erythromycin is recommended because relapses have been reported after completion of a seven-to 10-day treatment regimen. Erythromycin is classified as a Pregnancy Category B drug. Although animal reproduction studies have not demonstrated a risk to the fetus, no sufficient or well-controlled trials in humans exist.