Manitowoc County Health Department Pertussis Case Report Form
Name of Patient (Last, First, Middle Initial)
1 Native American / Alaskan Native 5 White
2 Asian / Pacific Islander 8 Other
Culture/PCR Was patient tested for Bordetella pertussis? PCR? ____Yes ____No Date: Culture? ____Yes ____No Date:
(Both a PCR and culture are recommended when testing for pertussis.)
Attenti on Health Care Provider: The information on this form is to be completed and faxed to the Manito
woc County Health Dept. (920-683-4156) within 24 hours on any patients meeting the following criteria –
Any pat ient tested (PCR and/or culture) for Bordetella pertussis
Any patient exhibiting symptoms of pertussis and prescribed antibiotic treatment (if testing was not done, please fax copy of notes from patient’s visit as well)
Any patients needing antibiotic treatment due to an exposure to pertussis If you hav
e questions or concerns, please contact our office at (920)683-4155. Thank you.rrhal (cold-like) symptoms started:________________
Date catarrhal (cold-like) cough started: ___________________ Paroxysmal cough: Yes No Whoop: Yes No
Sleep disturbance: Yes No Apnea: Yes No Vomiting: Yes No
Was patien t exposed to a known or suspect case of pertussis? Yes No If yes, please provide as much information as
possible about source of exposure (if there was no exposure, feel free to utilize this extra space for additional comments): me Isolation: If patient is symptomatic, did you instruct them that they must be on 5 day home isolation? Yes No
(Anyone sy mptomatic and on treatment, MUST be on home isolation for the first 5 days of appropriate treatment.) Treatmen t:Note – The antimicrobial agents and dosages used for chemoprophylaxis of contacts are the same as that ded for treatment of a clinical case.
Were antib iotics given? Yes No If yes, what date were antibiotics started? __________________
Number of days antibiotics are to be taken: _________ Check below as to which antibiotic was prescrib
Azithrom ycin Infants <6 months: 10mg/kg per day for 5 days.
Infants >6 months and children: 10 mg/kg (maximum 500 mg) day 1, followed by 5mg/kg per day (max. 250 mg) on days 2-5.
Adults 500 mg day 1, followed by 250 mg per day on days 2-5. Clarithro
mycin Infants < 1 month: not recommended.
Infants > 1 month and children: 15 mg/kg per day (maximum 1 g per day) in 2 divided doses each day for 7 days.
Adults 1 g per day in 2 divided doses for 7 days. Erythro
mycin Infants < 1 month: not preferred.
Infants > 1 month and older children: 40-50 mg/kg per day (maximum 2 g per day) in 4 divided doses for 14 days.
Adults 2 g per day in 4 divided doses for 14 days.
Trimethoprin-Sulfamethoxazole (TMP-SMZ) Alternative treatment for patients who have contraindications to the use of macrolides.
Infants < 2 months: contraindicated.
Infants > 2 months and children: trimethoprim 8mg/kg per day, sulfamethoxazole 40 mg/kg per day in 2 divided doses for 14 days.
Adults trimethoprim 320 mg per day, sulfamethoxazole 1,600 mg per day in 2 divided doses for 14 days.
Clinic Name and City:
________________________________________________________________________________________________________ Reporting Physician Name (please print legibly): ________________________________________________________________________________________________________ Name of CLINIC Contact Person and DIRECT Phone Number (if we have questions):
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