Last updated: September 11, 2023

Summarytoggle arrow icon

Pertussis, or whooping cough, is a highly infectious disease of the respiratory tract caused by the gram-negative bacterium Bordetella pertussis. This disease spreads via droplet transmission (and to a lesser extent via fomites) and most commonly occurs in children. Typically, pertussis manifests in three stages, with the second and third stages characterized by intense paroxysmal coughing that is followed by a distinctive whooping sound on inhalation and, in some cases, vomiting. Young infants may not develop the typical cough, and often present with apnea and cyanosis instead. Patients who meet the suspected case definition for pertussis should be started on antibiotic therapy for pertussis and confirmatory laboratory studies (usually PCR or culture) should be conducted. Postexposure prophylaxis for pertussis is recommended for all close contacts and high-risk individuals (e.g., infants) regardless of immunization status. Pertussis immunization is part of the routine immunization schedule; while immunization reduces the severity of illness it does not provide full immunity.

Epidemiologytoggle arrow icon

  • Pertussis is typically a childhood disease (particularly children aged < 1 year); however, older patients are increasingly affected. [1][2]
  • High rate of infections in newborns: The Tdap vaccine is recommended for pregnant individuals between 27 and 36 weeks' gestation. [1][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon


Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Pertussis classically has three stages: catarrhal, paroxysmal, and convalescent. Symptoms may vary, however, based on age and immunization status; vaccinated individuals tending to have a milder illness without characteristic whooping. [1][9]

Catarrhal stage (1–2 weeks) [9]

Paroxysmal stage (2–6 weeks) [9]

Convalescent stage (weeks to months) [9]

  • Progressive reduction of symptoms
  • Coughing attacks may persist over several weeks before resolving.
  • Patients have an increased susceptibility to respiratory infections.

The typical pattern of paroxysmal cough with whooping manifests mainly in unvaccinated children. Infants < 6 months of age, vaccinated individuals, and adults may not whoop and may not follow the classic stages of pertussis. [1][9]

Catarrhal stage manifests with Coryza, while the Paroxysmal stage manifests with Posttussive vomiting and whooPing cough.

Diagnosticstoggle arrow icon

Approach [1][10]

  • Perform confirmatory studies for any patient that meets the suspected case definition for pertussis. [9]
  • The choice of diagnostic test depends on duration since symptom onset. [9][11][12]
    • First 1–4 weeks: Obtain PCR ± culture.
    • Between 4—12 weeks: Consider a serum sample for serology. [9][12]
  • For infants < 3 months, consider a CBC.
    • Lymphocyte-predominant leukocytosis is common in infants and young children. [6]
    • An absolute lymphocyte count of > 20,000 cells/μL is a classic diagnostic finding and suggests a poor prognosis. [1][9]

Suspected case definition for pertussis [11][12][13]

Cough is present for any duration (with a low threshold for suspicion in infants), with ≥ 1 of the following: [9][13]

  • Paroxysmal coughing
  • Whooping on inspiration
  • Posttussive vomiting
  • Apnea [11][12]
  • Known contact with confirmed case
  • Living in an area with a pertussis outbreak

The presence of fever suggests an alternative diagnosis (see “Differential diagnoses of pertussis”). [9][13]

Confirmatory studies

PCR and/or cultures should be used for patients who present ≤ 4 weeks since cough onset. Serology should be used for patients who present > 4 weeks after developing symptoms.

PCR [1][6][11]

Bacterial culture [1][6][11]

Pertussis serology [6][9][11]

The CDC only accepts positive culture or PCR for disease reporting; serology is, however, suggested for use in outbreak settings. [6][12]

Direct fluorescent antibody testing and blood cultures are not recommended because of low specificity and sensitivity. [6][11][15]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [6]

Symptomatic treatment of cough (e.g., with corticosteroids, antihistamines, albuterol) is not recommended, as there is no evidence symptomatic treatments reduce cough or duration of hospitalization. [9][18]

Pertussis is a nationally notifiable disease. [9]

Admission criteria for pertussis

Infants < 6 months are at the highest risk for morbidity and mortality, especially those with a history of preterm delivery or inadequate maternal immunization. [6][20]

Antibiotic therapy for pertussis [1][6][9]

Antibiotic therapy decreases transmission of pertussis but may not improve the duration or severity of symptoms, especially if started at a later clinical stage. [1][11]

Monitor infants < 6 weeks of age who are being treated with azithromycin or erythromycin for hypertrophic pyloric stenosis. [6]

Acute management checklist for pertussistoggle arrow icon

Complicationstoggle arrow icon


We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

  • In children > 6 months: usually good; lengthy convalescence, but full recovery
  • In children < 6 months: increased risk of complications; mortality highest in children < 2 months [1][6]

Preventiontoggle arrow icon

Primary prevention of pertussis [24][25][26]

Pertussis vaccination helps reduce severity, but infection can still occur because the immunity from vaccination (as well as infection) is short-lived and there has been a rise in vaccine antigen-deficient strains. [9]

Ensure all close contacts (e.g., family members, caregivers) of infants have received all the recommended age-appropriate pertussis vaccines (DTaP, Tdap). [1][6][9]

Prevention of onward transmission of pertussis

Approach [6][11]

  • Use droplet precautions when evaluating patients.
  • Advise isolation precautions for pertussis for suspected or confirmed cases.
    • The duration of isolation precautions varies based on treatment status: [1]
      • Treated patients: until 5 days of antibiotic therapy have been completed
      • Untreated patients: > 3 weeks since cough onset
    • For patients in the community: [6]
      • Advise avoiding contact with high-risk individuals (i.e., pregnant women, infants, and children).
      • Children who attend daycare/school and staff in childcare and healthcare settings should remain at home.
    • For hospitalized patients: Place the patient in a side room with droplet precautions. [11]
  • Perform contact tracing to determine who should be offered postexposure prophylaxis for pertussis.
  • Pertussis is a notifiable disease; ensure the state health department has been contacted.

Postexposure prophylaxis for pertussis [6][10]

Referencestoggle arrow icon

  1. Hall E, Wodi AP, Hamborsky J, et al. Epidemiology and Prevention of Vaccine-Preventable Diseases 14th ed. Public Health Foundation ; 2021
  2. Gabutti G, Rota MC. Pertussis: a review of disease epidemiology worldwide and in Italy. Int J Environ Res Public Health. 2012; 9 (12): p.4626–4638.doi: 10.3390/ijerph9124626 . | Open in Read by QxMD
  3. Clark TA. Changing pertussis epidemiology: everything old is new again. J Infect Dis. 2014; 209 (7): p.978-91.doi: 10.1093/infdis/jiu001 . | Open in Read by QxMD
  4. CDC Yellow Book 2024: Pertussis / Whooping Cough. Updated: May 1, 2023. Accessed: August 23, 2023.
  5. Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients (2022) – Section Pertussis. Updated: November 2, 2022. Accessed: August 23, 2023.
  6. AAP Committee on Infectious Diseases. Red Book: 2021–2024 Report of the Committee on Infectious Diseases. American Academy of Pediatrics ; 2021
  7. Pertussis (Whooping Cough) - Disease Specifics. Updated: September 8, 2015. Accessed: March 19, 2017.
  8. Carbonetti NH. Pertussis toxin and adenylate cyclase toxin: key virulence factors ofBordetella pertussisand cell biology tools. Future Microbiol. 2010; 5 (3): p.455-469.doi: 10.2217/fmb.09.133 . | Open in Read by QxMD
  9. Nemhauser JB. CDC Yellow Book 2024. Oxford University Press ; 2023
  10. Kline JM, Smith EA, Zavala A. Pertussis: Common Questions and Answers. Am Fam Physician. 2021; 104 (2): p.186-192.
  11. Pertussis: Vaccine Preventable Diseases Surveillance Standards. Updated: September 4, 2018. Accessed: May 25, 2023.
  12. Pertussis (Whooping Cough) (Bordetella pertussis) 2020 Case Definition. Updated: April 16, 2021. Accessed: May 31, 2023.
  13. Moore A, Harnden A, Grant CC, et al. Clinically Diagnosing Pertussis-associated Cough in Adults and Children. Chest. 2019; 155 (1): p.147-154.doi: 10.1016/j.chest.2018.09.027 . | Open in Read by QxMD
  14. Pertussis (Whooping Cough) Specimen Collection and Diagnostic Testing. Updated: August 4, 2022. Accessed: May 10, 2023.
  15. Janda WM, Santos E, Stevens J, Celig D, Terrile L, Schreckenberger PC. Unexpected isolation of Bordetella pertussis from a blood culture. J Clin Microbiol. 1994; 32 (11): p.2851-3.doi: 10.1128/jcm.32.11.2851-2853.1994 . | Open in Read by QxMD
  16. Surridge J, Segedin ER, Grant CC. Pertussis requiring intensive care. Arch Dis Child. 2007; 92 (11): p.970-975.doi: 10.1136/adc.2006.114082 . | Open in Read by QxMD
  17. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  18. Wang K, Bettiol S, Thompson MJ, et al. Symptomatic treatment of the cough in whooping cough. Cochrane Database Syst Rev. 2014; 2014 (9): p.CD003257.doi: 10.1002/14651858.CD003257.pub5 . | Open in Read by QxMD
  19. Cherry JD. Pertussis in Young Infants Throughout the World. Clin Infect Dis. 2016; 63 (suppl 4): p.S119-S122.doi: 10.1093/cid/ciw550 . | Open in Read by QxMD
  20. Mbayei SA, Faulkner A, Miner C, et al. Severe Pertussis Infections in the United States, 2011-2015. Clin Infect Dis. 2019; 69 (2): p.218-226.doi: 10.1093/cid/ciy889 . | Open in Read by QxMD
  21. Brooks D, Clover R. Pertussis infection in the United States: role for vaccination of adolescents and adults. J Am Board Fam Med. 2006; 19 (6): p.603-11.
  22. Monaco F, Barone M, Manfredi VG et al. Pneumomediastinum as a complication of critical pertussis. Clin Respir J. 2016; 10 (6): p.772-776.doi: 10.1111/crj.12285 . | Open in Read by QxMD
  23. Long SS, Prober CG, Fischer M. Principles and Practice of Pediatric Infectious Diseases E-Book. Elsevier Health Sciences ; 2017
  24. Child and Adolescent Immunization Schedule. Recommendations for Ages 18 Years or Younger, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  25. Catch-up Immunization Schedule for Children and Adolescents Who Start Late or Who Are More than 1 Month Behind Recommendations for Ages 18 Years or Younger, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  26. Adult Immunization Schedule by Age Recommendations for Ages 19 Years or Older, United States, 2023. Updated: February 10, 2023. Accessed: March 24, 2023.
  27. Infection Control in Healthcare Personnel: Epidemiology and Control of Selected Infections Transmitted Among Healthcare Personnel and Patients. Updated: January 1, 2022. Accessed: June 22, 2023.

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