الرحیم الرحمن الله بسم

Bordetella pertussis

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

Roxana M.Ghanaie

Ped Infectious Disease Subspecialist

Bordetella pertussis Basics

• Aerobic, Gram negative coccobacillus• Alcaligenaceae Family• Specific to Humans• Colonizes the respiratory tract

– Whooping Cough (Pertussis)

Bordetella pertussisBordetella pertussis

Jules Bordet1870-1961

is a bacterium identified in 1900 by Jules Bordet and Octave Gengou but isolated only in 1906 because of the development of a medium containing potatoes extract and rabbit blood

Source: 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 age1.4 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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Pertussis in a vaccinated country vs a non vaccinated country

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Why speaking about Pertussis?

• Iran pertussis incidence 2010 : 0.5/ 100000• DTP3 coverage more than 95%

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سياه محتمل موارد فراوانيعلوم دانشگاه برحسب سرفه

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Bordetella pertussis virulence determinantsBordetella pertussis virulence determinants

Adhesins: adhesion => multiplication and colonisation of respiratory tract

Toxins: local and systemic cytopathogenic effects

Filamentous hemagglutinin

(FHA)

Pertactin (PRN)

Fimbriae (FIM)

TCT

Adenylate cyclase hemolysin (AC-Hly)

Pertussis toxin (PT)

TCT

BrkA, Tcf, Vag8

TCT

• The incubation period of pertussis is usually 7 to 10 days, with a range of 4 to 21 days.

• The clinical course of illness is divided into three stages.( age, vaccination, waning)

1/ 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)

Classic Manifestation

• 2/ 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

Classic Manifestation

• 3/The convalescent stage is characterized by fewer paroxysmal coughing episodes and usually disappears in 2-3 weeks, but may continue for months

Complications• Losing weight, pneumonia, otitis, seizure,

encephalopathy, apnea• Epistaxia, melena, subdural hematoma,

inguinal hernia, rectal prolapse,

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.

Short catarrhal period, longer convalescence periodCough,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).

Infants

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

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

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. pertussis infections for infants,

• grandparents, uncles , Aunts also provide another potential source of infection

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

B. parapertussis• B. parapertussis infection in humans can cause

unrecognized infection, mild pertussis, or classic pertussis

• B. bronchisepica

DD prolonged cough

• Adenovirus• Para influenza• Influenza A,B• M.pneumonia• RSV• C.trachomatis• C. pneumonia

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

• 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.

CXR Indications

• 1/ <1y• 2/ toxic• 3/ progressive cough>3 w• 4/ res distress• 5/ probable underlying dis( CF, CHD,forign

body, Hilar LAD)

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

Diagnosis

• Isolation by culture , preferred method of diagnosis(100% specificity)

• Although PCR more sensetive,culture may be necessary for further case analysis including evaluation for

antibiotic resistance and molecular typing

http://medinfo.ufl.edu/year2/mmid/bms5300/images/d7053.jpg

• Neg culture: • Previously immunized• Antibiotic usage• More than 3 w after cough onset• Bad-handled specimen

Definition:

Clinical Case Definition of Pertussis • A cough illness lasting at least 14 days with

one of the following: • paroxysms of coughing, • inspiratory “whoop”,• or post-tussive vomiting,• and without other apparent cause (as

reported by a health professional).

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 • Serology and DFA results should not be relied on as a

criterion for laboratory confirmation of pertussis.

Definition:

Pertussis Case Classification

• Confirmed: a/ A positive culture for B. pertussis and 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.

• 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

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.

Suspect: a clinical syndrome compatible with pertussis; an illness consistent with pertussis and without other apparent cause, such as:

• a. cough of ≥ 7 days, or • b. paroxysmal cough of any duration, or • c. cough with inspiratory whoop, or • d. cough associated with apnea in an infant, or • e. cough in a close contact of a confirmed or

probable case. Summary of Pertussis Investigation and Control Guidelines Colorado Department of Public Health and Environment Communicable Disease Epidemiology Program

سرفه سياه بيماري مراقبت

مشمول هاي بيماري دسته از سرفه سياه.فوريگزارشدهي باشد مي

اساس بر بيماري مورد مراقبت بيماري مبناي. شود مي انجام

شروع از قبل است الزم محتمل مورد هربرداري درمان نمونه مركز جهت آزمايشگاه به

شود ارجاع بهداشت مراقبت سطوح تمامي انجام گزارشدهيدر

وجود بيماري مورد كه مواردي در گيرد، ميگزارش ارسال الزامي صفرندارد بيماري

است.

Management:

• The desired outcomes are:1/ observing the severity of cough2/ limiting the number of paroxysms, 3/ providing assistance when necessary, 4/ maximizing nutrition, rest, and recovery, 5/ follow the course of disease 6/ prevent/treat complications

• Admitt:1- all infants<3 m despite severity & all 3-6 m except the

attacks are mild as observed by physician2- 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

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.

Management:

• Oxygen,suction,hydration, nutrition• Patients who are severely ill may require treatment in an

ICU.• Investigate all probable, pertussis reports. • Recommend antibiotics for the index case (first case

reported to public health authorities), all household and close contacts. Antibiotic inspite of age, immunization Hx

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)

• Evaluate close contacts for pertussis symptoms, and when possible collect specimens for lab testing from symptomatic persons

• 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

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

Treatment

• Antibiotic therapy– Erythromycin– Azithromycin– Clarithromycin

http://www.aboutthatbug.com/AboutThatBug/files/CCLIBRARYFILES/FILENAME/0000000032/033_lg.jpg http://www.vet.purdue.edu/bms/courses/lcme510/chmrx/macrohd.htm

Treatment

ErythromycinFor children: 40-50 mg/kg/d in 4 divided

doses;10-14 days• For adults: 1 to 2 g/day given every 6 h

Treatment

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

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

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

Treatments

Trimethoprim(T)/Sulfamethoxazole (S)8mg/kg T + 40 mg/kg S/d in 2divided 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

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.

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

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

Exclusions fromwork/school

Symptomatic: first 5 days of treatment

Symptomatic, refuses treatment: exclude for 21 days from onset of symptoms

Asymptomatic exposure: no exclusion

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( ???)

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.

Use a narrow definition ofclose 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).

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

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

QUESTIONS?

Diphtheria

Etiology

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. اولسرنس باکتریوم کورینه

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Etiology

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حال • در و جوانتر های باسیل توسط بیشتر سم . شود می تولید سریع نمو و رشد

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Etiology

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. کنند می عمل باسیل مخزن• : بیماری روز 7-2کمون

Clinical Manifestation

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. شود می تقسیم غیره

Clinical Manifestationتنفسی • بصورت دیفتری معموال

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. دارد موضعی ضایعه

Clinical Manifestation

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. است زیاد دیگران به ابتال و بیماری انتشار خطر. دارد وجود شیرخواران در بیشتر فرم این

Clinical Manifestation• : حلق و لوزه و دیفتری تدریجی بیماری شروع

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ایمنی • وضعیت به بسته ان گسترش شدت. است متغیر بیمار

بوده • خاکستری به متمایل زرد رنگ غشا. دارد چسبندگی لوزه به بسختی و

•. است درگیر کوچک زبان اغلب

Clinical Manifestation

نا • و بد بسیار دهان بوی غشا نکروز اثر در . و بزرگ اکثرا لنفاوی غدد است مطبوع

. است حساسنسوج • و لنفاوی غدد تورم شدید اشکال در

گردن شدید تورم بصورت انسداد نرم با همراه . این کند می بروز فوقانی هوایی راههای

. است سفت و دردناک گذار، گوده گرم، تورمباالی • کودکان در شود 6بیشتر می دیده سال

و گراویس های سویه توسط معموال وشود می ایجاد اینترمدیوس

Clinical Manifestation

شدن • ازاد میزان به بسته عالئم شدت . دارد غشا گسترش و توکسین

• ، عروق کوالپس ، شدید موارد دربینی، از خونریزی تنفسی، کوالپس

پورپورا و منتشر خونریزی گاه دهان،ظاهر و است بد عمومی حال دارد، وجودوجود تب است رنجور و پریده رنگ بیمار

نبض تعداد ولی است خفیف یا و ندارد . است باال نامتناسب بطور

دو • یا و یکطرفه بطور کام فلج است ممکنوجود بینی از غذا برگشت و بلع اشکال ، طرفه

. باشد داشتهعرض • در ومرگ هشیاری،کوما 10تا 7اختالل

. افتد می اتفاق روز• . موارد در دارد محیطی نوروپاتی و میوکاردیت

منجر وگاه است تر آهسته بهبود ، کمتر شدت با . موارد در شود می نوریت و میوکاردیت به

عرض در غشا و است متغیر بهبود زمان خفیف7-10. شود می کنده روز

حلق • دیفتری در توکسین جذب از ناشی عوارضاست قسمتها سایر دیفتری از تر شدید لوزه و

حنجره :دیفتری•. دارد فوری اقدام به نیاز ،گاه طب اورژانسمی • وندرتا است حلق دیفتری به ثانویه اغلب

. تیس می سویه بدنبال اغلب باشد اولیه تواندشود می فارنژیت ایجاد خالف بر اینموارد در

ومی نیست متصل بسختی غشا دیفتری،تنفسی مجرای انسداد باعث و شده جدا تواند

. است. کروپ موارد سایر شبیه عالئم شودعوارض • و بوده کم توکسین جذب اینموارد در

. شود می دیده بندرت آن

Transmission

و • قطرات طریق از انتشار معمول بطوراز پوست و ،بینی حلق ترشحات با تماس

. شود می انجام ناقل فرد یا و بیمارتواند • می باسیل درمان عدم صورت در

زخم در یا و حلق یا و بینی شحات تر دراز چشم یا و از 6تا 2پوست بعد هفته. بماند زنده آلودگی

برای • سرایت مناسب درمان صورت دراز کمتر است 4مدت پذیر امکان روز

Transmission

بیماران • با نزدیک ازتماس ناشی انتقالمناطق به سفر در بخصوص ناقلین یا و

اندمیک مناطق از مسافرین یا و اندمیکاست.

آلوده، • اشیائ طریق از دیفتری بندرتمی منتقل لبنیات سایر ویا شیرخام

بین. از باسیل شیر جوشیدن اثر در شودرود می

بیماری مورد تعریفبیماری • مورد بالینی که: تعریف بیماری هر

فارنژیت، باچسبنده غشائ بهمراه تونسیلیت یا و رنژیت ال

. نماید مراجعه بینی یا و حلق ها، لوزه روی

ازمایشگاهی اثبات معیار:بیماری

از • دیفتری باکتریوم کورینه کردن جداچهار حداقل افزایش یا و بالینی نمونه

دو در سرم بادی آنتی تیتر در برابرنمونه ( دو هر صورتیکه در متوالی نمونه

انتی یا و توکسوئید تجویز از قبل( باشد توکسین

موارد بندی گروه محتمل • داشته: مورد را بالینی معیار که است موردی

باشد.قطعی • دارای: مورد بالینی معیارهای بر عالوه که موردی

اپیدمیولوژیک ارتباط یا و باشد نیز ازمایشگاهی معیارهای . باشد داشته بالینی شده ثابت مورد با شده تایید

هستند: • بالینی عالیم فاقد که را مواردی تبصره ( نباید ( سالم ناقلین است مثبت انها در کشت ولی

. نمود گزارش قطعی یا و محتمل موارد بعنوان

Management

1/ Critical care needs 2/ Neutrilize toxin3/ Eradicate C. diphtheria4/ Complications• Mechanical ventilation (combination of

airway obstruction by the diphtheritic membrane and peripharyngeal edema )

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

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.

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.

Antitoxin

اساس • بر سم ضد تزریقی اندازه دوز و محلزمان مدت و سم اثرات شدت دیفتری، غشای

بیماری :شروع شود می تعییننشاندهنده • نرم و منتشر گردنی لنفادنوپاتی وجود

است سم شدید تا متوسط جذبمساوی • یا و کمتر بمدت حنجره یا و حلق درگیری

واحد 40000-20000ساعت، 48فارنژیال • نازو واحد 60000-40000درگیریبمدت • یا گسترده یا شدید یا 3بیماری و روز

گردن شدید تورم یا و واحد 120000-80000بیشتربعضی • ولی ندارد اثر معموال پوستی دیفتری در

کنند 20000-40000 می توصیه را واحد

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

Antimicrobial

تزریقی • یا و خوراکی مایسین 14بمدت اریتروحداثر 50-40روز( وزن، کیلوگرم هر 2بازای

( روز در گرمسیلین • واحد 100-150000- تزریقی Gپنی

در منقطع وزن کیلوگرم هر ) 4بازای داخل دوزمدت برای روز 14وریدی

سیلین • عضالنی پروکایین Gپنی تزریقیبدن 50000-25( وزن کیلوگرم هر بازای واحد

( بمدت منقسم دوز دو در روز 14روزانه

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

Vaccine

• Diseases dose not produce immunity, vaccinate the patient in convalescent period

Surgical Care

• Otolaryngeal assessment is needed in patients with severe respiratory or neurologic complications or as part of critical care.

Consultation

Cardiologist: Elevation of serum SGOT closely 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

• Neurologist: • parallel the extent of primary infection and are

multiphasic in onset.• Hypersthesia and local paralysis of the soft

palate • Weakness of the posterior pharyngeal,

laryngeal, and facial nerves , causing a nasal tone in the voice, difficulty in swallowing, and risk of death from aspiration.

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.

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.

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 10 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)

Contacts

• 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)

Mortality/Morbidity

• Death due to mechanical airway obstruction or cardiac involvement with circulatory collapse

• In at least 10% of patients with respiratory tract diphtheria

Mortality/MorbidityPrognosis depends on:• The virulence of the organism (with the gravis

strain usually accounting for the most severe disease),

• The age and immunization status of the patient, • The site of involvement, • The speed with which antitoxin is administered

Mortality/Morbidity

• Airway obstruction by the diphtheritic membrane and peripharyngeal edema combine to pose a risk of death in patients with diphtheria.

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%

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.

دیفتری بیماری مراقبت

پائین • بیماری بروز میزان که کشورما دراز بیش ایمنی پوشش میزان و 90است

و محتمل مورد هر اطالعات است درصدبرمورد قطعی و مبتنی سطوح بوده از

فوری گزارش بصورت باال به پائین . اطالعات از شود می انجام تلفنی

و پایش جهت توان می مراقبت سیستمبخشی اثر نتیجه عنوان به بیماری بروز

. کرد استفاده کنترل های برنامه

اولين در الزم اقداماتبه بيمارمحتمل با برخورد

-ديفتري فوري دهي بيماريگزارش- بيمار سازي از جدا نمونه دو كشت كه وقتي تا

وبيني حلق ترشحات . امكان اگر شوند منفي باسيل نظروجود از

نباشد موجود روز14كشتمناسب هاي بيوتيك آنتي با درمان اتمام از پس

داد خاتمه را بيمار سازي جدا توان .ميبيمار توكسين - به آنتي محل تزريق برحسب

بيماري ت شد و ضايعهبيوتيك - آنتي با تزريق جي پروكائين سيلين پني

به بالغ افراد و كودكان براي مربوطه دزهاي.روز 14مدت

TREND OF PROBABLE DIPHTERIA CASES INCEDENCE RATES

& DTP3 COVERAGE (I.R.IRAN 1370-1391)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

1370

1371

1372

1373

1374

1375

1376

1377

1378

1379

1380

1381

1382

1383

1384

1385

1386

1387

1388

1389

1390

1391

INC

ED

EN

CE

RA

TE

/100

.000

82

84

86

88

90

92

94

96

98

100

CO

VE

RA

GE

DIPHTERIA DTP3

دیفتری محتمل موارد فراوانيپزشکی علوم دانشگاه برحسب

1391

0

20

40

60

80

100

120

140

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QUESTIONS?