Abigail Moore1, Anthony Harnden2, Cameron C Grant3, Sheena Patel4, Richard S Irwin5. 1. Department of Primary Heath Care Sciences, University of Oxford, Oxford, England. Electronic address: abigail.moore@phc.ox.ac.uk. 2. Department of Primary Heath Care Sciences, University of Oxford, Oxford, England. 3. Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand. 4. CHEST Organization, Department of Medicine, UMass Memorial Medical Center, Worcester, MA. 5. Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, UMass Memorial Medical Center, Worcester, MA.
Abstract
BACKGROUND: The decision to treat a suspected case of pertussis with antibiotics is usually based on a clinical diagnosis rather than waiting for laboratory confirmation. The current guideline focuses on making the clinical diagnosis of pertussis-associated cough in adults and children. METHODS: The American College of Chest Physicians (CHEST) methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on findings from a systematic review that was recently published on the topic; final grading was reached by consensus according to Delphi methodology. The systematic review was carried out to answer the Key Clinical Question: In patients presenting with cough, how can we most accurately diagnose from clinical features alone those who have pertussis-associated cough as opposed to other causes of cough? RESULTS: In adults, after pre-specified meta-analysis exclusions, pooled estimates of sensitivity and specificity were generated for only 4 clinical features: paroxysmal cough, post-tussive vomiting, inspiratory whooping, and absence of fever. Both paroxysmal cough and absence of fever had high sensitivity (93.2% [95% CI, 83.2-97.4] and 81.8% [95% CI, 72.2-88.7], respectively) and low specificity (20.6% [95% CI, 14.7-28.1] and 18.8% [95% CI, 8.1-37.9]). Inspiratory whooping and posttussive vomiting had a low sensitivity (32.5% [95% CI, 24.5-41.6] and 29.8% [95% CI, 18.0-45.2]) but high specificity (77.7% [95% CI, 73.1-81.7] and 79.5% [95% CI, 69.4-86.9]). In children, after pre-specified meta-analysis exclusions, pooled estimates of sensitivity and specificity were generated for only 1 clinical feature in children (0-18 years): posttussive vomiting. Posttussive vomiting in children was only moderately sensitive (60.0% [95% CI, 40.3-77.0]) and specific (66.0% [95% CI, 52.5-77.3]). CONCLUSIONS: In adults with acute (< 3 weeks) or subacute (3-8 weeks) cough, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children with acute (< 4 weeks) cough, posttussive vomiting is suggestive of pertussis but is much less helpful as a clinical diagnostic test. Guideline suggestions are made based upon these findings and conclusions.
BACKGROUND: The decision to treat a suspected case of pertussis with antibiotics is usually based on a clinical diagnosis rather than waiting for laboratory confirmation. The current guideline focuses on making the clinical diagnosis of pertussis-associated cough in adults and children. METHODS: The American College of Chest Physicians (CHEST) methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on findings from a systematic review that was recently published on the topic; final grading was reached by consensus according to Delphi methodology. The systematic review was carried out to answer the Key Clinical Question: In patients presenting with cough, how can we most accurately diagnose from clinical features alone those who have pertussis-associated cough as opposed to other causes of cough? RESULTS: In adults, after pre-specified meta-analysis exclusions, pooled estimates of sensitivity and specificity were generated for only 4 clinical features: paroxysmal cough, post-tussive vomiting, inspiratory whooping, and absence of fever. Both paroxysmal cough and absence of fever had high sensitivity (93.2% [95% CI, 83.2-97.4] and 81.8% [95% CI, 72.2-88.7], respectively) and low specificity (20.6% [95% CI, 14.7-28.1] and 18.8% [95% CI, 8.1-37.9]). Inspiratory whooping and posttussive vomiting had a low sensitivity (32.5% [95% CI, 24.5-41.6] and 29.8% [95% CI, 18.0-45.2]) but high specificity (77.7% [95% CI, 73.1-81.7] and 79.5% [95% CI, 69.4-86.9]). In children, after pre-specified meta-analysis exclusions, pooled estimates of sensitivity and specificity were generated for only 1 clinical feature in children (0-18 years): posttussive vomiting. Posttussive vomiting in children was only moderately sensitive (60.0% [95% CI, 40.3-77.0]) and specific (66.0% [95% CI, 52.5-77.3]). CONCLUSIONS: In adults with acute (< 3 weeks) or subacute (3-8 weeks) cough, the presence of whooping or posttussive vomiting should rule in a possible diagnosis of pertussis, whereas the lack of a paroxysmal cough or the presence of fever should rule it out. In children with acute (< 4 weeks) cough, posttussive vomiting is suggestive of pertussis but is much less helpful as a clinical diagnostic test. Guideline suggestions are made based upon these findings and conclusions.
Authors: P Strebel; J Nordin; K Edwards; J Hunt; J Besser; S Burns; G Amundson; A Baughman; W Wattigney Journal: J Infect Dis Date: 2001-03-30 Impact factor: 5.226
Authors: Penny F Whiting; Anne W S Rutjes; Marie E Westwood; Susan Mallett; Jonathan J Deeks; Johannes B Reitsma; Mariska M G Leeflang; Jonathan A C Sterne; Patrick M M Bossuyt Journal: Ann Intern Med Date: 2011-10-18 Impact factor: 25.391
Authors: Anthony Harnden; Cameron Grant; Timothy Harrison; Rafael Perera; Angela B Brueggemann; Richard Mayon-White; David Mant Journal: BMJ Date: 2006-07-07
Authors: Jolien Teepe; Berna D L Broekhuizen; Margareta Ieven; Katherine Loens; Kris Huygen; Mirjam Kretzschmar; Hester de Melker; Chris C Butler; Paul Little; Beth Stuart; Samuel Coenen; Herman Goossens; Theo J M Verheij Journal: Br J Gen Pract Date: 2015-10 Impact factor: 5.386
Authors: Abigail Moore; Helen F Ashdown; Bethany Shinkins; Nia W Roberts; Cameron C Grant; Daniel S Lasserson; Anthony Harnden Journal: Chest Date: 2017-05-13 Impact factor: 9.410
Authors: Kian Fan Chung; Lorcan McGarvey; Woo-Jung Song; Anne B Chang; Kefang Lai; Brendan J Canning; Surinder S Birring; Jaclyn A Smith; Stuart B Mazzone Journal: Nat Rev Dis Primers Date: 2022-06-30 Impact factor: 65.038
Authors: Yunlei Li; Chantal B van Houten; Stefan A Boers; Ruud Jansen; Asi Cohen; Dan Engelhard; Robert Kraaij; Saskia D Hiltemann; Jie Ju; David Fernández; Cristian Mankoc; Eva González; Wouter J de Waal; Karin M de Winter-de Groot; Tom F W Wolfs; Pieter Meijers; Bart Luijk; Jan Jelrik Oosterheert; Sanjay U C Sankatsing; Aik W J Bossink; Michal Stein; Adi Klein; Jalal Ashkar; Ellen Bamberger; Isaac Srugo; Majed Odeh; Yaniv Dotan; Olga Boico; Liat Etshtein; Meital Paz; Roy Navon; Tom Friedman; Einav Simon; Tanya M Gottlieb; Ester Pri-Or; Gali Kronenfeld; Kfir Oved; Eran Eden; Andrew P Stubbs; Louis J Bont; John P Hays Journal: PLoS One Date: 2022-04-18 Impact factor: 3.240
Authors: Ahmad Kantar; Julie M Marchant; Woo-Jung Song; Michael D Shields; Grigorios Chatziparasidis; Angela Zacharasiewicz; Alexander Moeller; Anne B Chang Journal: Front Pediatr Date: 2022-04-15 Impact factor: 3.418
Authors: Leticia Burton; Daminda P Weerasinghe; David Joffe; Jennifer Saunders; Gregory L Falk; Hans Van der Wall Journal: Multidiscip Respir Med Date: 2022-07-06
Authors: Amit Bhavsar; Emmanuel Aris; Lauriane Harrington; Jason C Simeone; Anna Ramond; Dimitra Lambrelli; Alberto Papi; Louis-Philippe Boulet; Kinga Meszaros; Nicolas Jamet; Yan Sergerie; Piyali Mukherjee Journal: J Asthma Allergy Date: 2022-01-11