Pertussis in Missouri: Evaluation of Nasopharyngeal Culture, Direct Fluorescent Antibody Testing, and Clinical Case Definitions in the Diagnosis of Pertussis

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Abstract
No diagnostic test for pertussis in routine use in the United States has both high sensitivity and high specificity. During a statewide increase in the incidence of pertussis in Missouri, we studied the clinical features of 153 patients with suspected pertussis in the Greater St. Louis area from whom a specimen for pertussis culture had been taken between 15 May and 19 September 1989. In this cross-sectional study, nasopharyngeal cultures were more likely to be positive for persons whose specimens were collected a] and 95% confidence interval = 3.4; 1.5–8.0) and who were not receiving erythromycin/sulfamethoxazole prior to the culture [RRa = 5.8; 0.8–40.6], who had received fewer than three prior doses of pertussis vaccine [RRa = 1.8; 0.8–4.2], and whose specimen was in transit to the laboratory for a = 2.0; 0.8–5.5]. Among children 10,000/mm3 was the acute symptom complex associated with the highest predictive value for a positive culture result (67%). Cough for ⩾ 14 days plus whoop was sensitive (81%) and specific (58%) for identifying children with culture-confirmed pertussis. Direct fluorescent antibody staining performed well as a screening test for pertussis but requires substantial commitment of personnel and resources. In the absence of a positive culture result, clinical case definitions should be used for decision making (e.g., initiation of antimicrobial therapy and routine case reporting).

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