Microlife: GPFrom your local Clinical Microbiology Team

O c t o b e r 2 0 1 2

In this edition we provide

an update on how to

diagnose Pertussis and

a d v i c e o n M R S A

decolonisation treatment in

the community.

We hope you find this

newsletter useful. Please

send any comments to:

Savita.gossain@heartofengland

.nhs.uk 

WelcomePertussis on the increase

Laboratory Opening

Hours:

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Holidays: 8am - 4pm

Clinical enquiries:

Heartlands Hospital:

Microbiology Consultant

0121 424 3244

Good Hope Hospital:

Microbiology Consultant

07917 648323

Heartlands Hospital:

Virology enquiries:

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Out of Office Hours:

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0121 424 2000

Whooping cough (pertussis) is a

notifiable, highly contagious,

acute bacterial infection of the respiratory

tract caused by Bordetella pertussis.1 

It affects people of all ages and can

result in substantial morbidity and

mortality.

In the first 33 weeks of 2012 there have

been 5,657 cases, an eight-fold increase

from this time last year with eight reported

deaths. These deaths have all been in

young unimmunised infants.2 

The highest numbers of confirmed cases

continue to be reported in the South East

and South West Regions but activity is

high across all parts of the country.

Why are rates increasing?

Several factors may account for the

apparent rise in pertussis cases, including

increased awareness, new diagnostic

methods and reduced potency of the

acellular pertussis vaccine compared to

the earlier whole cell vaccine. Previous

infection or vaccination does not

confer lifelong immunity to pertussis.

Infections with whooping cough in

vaccinated or previously infected patients

are likely to be milder.

How infectious is pertussis?

Up to 90% of non-immune household

contacts are likely to develop the disease.

It is spread by close contact with an

infected person. Patients are infectious up

to four days before the cough develops,

and for about 21 days following the onset

of symptoms.

What are the symptoms of pertussis?

Incubation period typically 7 - 10 days.

Patients initially develop a common

cold-like illness.

Outbursts of coughing (paroxysms)

within one to two weeks.

 An inspiratory whoop.

Coughing bouts may be followed by

vomiting or apnoeic episodes.

Sufferers may produce thick, sticky,

clear sputum, that is often very difficult

to expectorate. This gradually worsens

and lasts over a period of 2-6 weeks.

Suspect pertussis in anyone with a

chronic paroxysmal cough, a ‘whoop’ 

is not always present.

Who is most at risk?

The highest incidence has been

observed in infants under 3 months.

These infants are too young to be

protected by immunisation, are at greater 

risk of developing the disease and are

also at much greater risk of developing

complications, hospitalisation and death.

The DH recently introduced a temporary

programme to vaccinate pregnant women

against pertussis to protect their infants.3 

Laboratory results:

For all results enquiries,

contact: 0121 424 3256  How to diagnose pertussis 

For diagnostic purposes, the disease is divided into early (<2 weeks from start of symptoms) and late (>2 weeks). 

Infants (if not requiring hospitalization)  send culture swab (see overleaf) 

Children over 12 months and

adults: 

Early disease  send culture swab (see overleaf) 

Late disease  send sample for serology (red toptube) NB: serology result only valid if not

vaccinated in the previous year  

 

MRSA and Decolonisation

It is routine at the Heart of England NHSFoundation Trust to take a nose swab for MRSA

(Methicillin Resistant Staphylococcus aureus) fromall patients admitted to our hospitals

If the patient is positive they are treated with anantiseptic body wash and nasal cream(decolonisation treatment) whilst in hospital.

In some cases screening results may not beavailable until after the patient is discharged andtherefore your patient will not have had anytreatment. In these cases, we inform the patient andGP by automatic letter of a positive result so theneed for treatment can be assessed.

Most patients will not require any decolonisationtreatment and can be reassured that MRSA that wasdetected will go naturally. However, patients withlong standing illnesses, catheters, wounds and ivlines are at higher risk of developing an infection andwe would recommend they are prescribeddecolonisation treatment.

On completion of the 5 day course of de-colonisation, repeat swabbing is not usually required,unless clinically indicated.

There is an information leaflet advising patients onhow to use decolonisation treatment, and followingfeedback from GPs, these will, in future, be sent with

the letter to the practice.If you have any queries, comments or require

further advice please contact a member of theInfection Prevention and Control Team (0121 4241137) or Duty Microbiologist (see page 1).

MRSA Decolonisation treatment

Five days of anti-septic body wash Chlorhexi-dine Gluconate 4% Solution OD and a nasalcream Bactroban Nasal Ointment(Mupirocin 2% Nasal Ointment) TDS usedas follows:

The body wash should be used as a liquidsoap and applied directly on to the skin (notdiluted).

The patient should preferably shower or bathe daily and wash their hair twice in the5 day period with Chlorhexidine.

 A small amount of the nasal cream shouldbe applied to the inner surface of each nos-tril TDS for the 5 day period. 

N.B. For patients allergic to Chlorhexidine,Octenisan Wash Lotion can be used as analternative in same way as above.  

How to take a pernasal swab

 A pernasal swab must be takencorrectly to ensure an accuratediagnosis of pertussis can bemade. Swabs can be orderedfrom Pathology Stores in theusual way.

1. Remove cap from media tube

by twisting.

2. Gently insert the fine, flexible

pernasal (turquoise top) swab

along the floor of the nasal cavity

until it touches the posterior naso-

pharynx & rotate 2-3 times before

withdrawing. If obstruction is en-

countered, withdraw and re-insert

through other nostril.

3. Insert the swab into the me-

dia tube.

4. Ensure the swab is labelledaccurately along with the com-

pleted request form. Send to lab ASAP.

Notification of pertussis

In all patients that you suspect 

have whooping cough notify your 

regional HPU immediately on

0844 225 3560.

DO NOT wait for a laboratory

diagnosis and confirmation.

How to treat pertussis

For suspected, epidemiologi-cally linked or confirmed cases,recommended antibiotic regimensaccording to the age of the patientare available on the HPA website(Ref.1).

Erythromycin, clarythromycin,azithromycin and co-trimoxazoleare all recommended but differ according to the age of the pa-tient.

 Antibiotics should be adminis-tered as soon as possible after onset of illness in order to eradi-cate the organism and limit ongo-ing transmission.

Pertussis increase ctd...

References 

1.HPAGuidelines.http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287142671506; 2. Health Protection Agency. Pertussis

notifications and deaths. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317133571994; 3. https://www.cas.dh.gov.uk/ 

ViewandAcknowledgment/ViewAlert.aspx?AlertID=101844 

Sagittal section of the nasal airway,reproduced from Medical Microbiology Testing in Primary Care, MansonPublishing.