Speaker 1  00:05
Lange, welcome to HelixTalk, a podcast presented by the Rosalind Franklin University College of Pharmacy.

Narrator - Dr. Abel  00:11
This podcast is produced by pharmacy faculty to supplement study material and provide relevant drug and professional topics.

Speaker 1  00:19
We're hoping that our real life clinical pearls and discussions will help you stay up to date and improve your pharmacy knowledge.

Narrator - Dr. Abel  00:27
This is an educational production copyright Rosalind Franklin University of Medicine and Science.

Speaker 1  00:32
This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - Dr. Abel  00:47
And now on to the show.

Dr. Sean Kane  00:51
Welcome to Episode 11 of HelixTalk. I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel, and we actually have a special guest here, and I'll let him introduce himself and some of his background. We're really excited to have him today.

Speaker 2  01:04
So my name is Mike Fennewald, and I'm a faculty member in the Microbiology and Immunology department here at Roslyn franklin. I got a PhD at the University of Chicago in microbiology and immunology, and I've been on the faculty here for 25 years. Perfect. Welcome, Dr. Fennewald.

Dr. Sean Kane  01:21
well, welcome so. Dr. Fennewald, well, we wanted to have you come in here today as part of, as you know, the mission of Rosalind Franklin is a very interprofessional environment, and we thought it'd be great to have you come in. And I know that one of the topics that you wanted to discuss today is Bordetella pertussis. What made you want to pick that topic for today?

Speaker 2  01:38
Well, there were a number of reasons. First of all, Bordetella pertussis causes two different clinical syndromes, and in infants and children, the syndrome is usually called whooping cough. But in teens and adults, the syndrome appears as like a cold with a tremendously lingering cough. So I can

Dr. Sean Kane  01:56
probably appreciate then, if, let's say in adults, the syndrome may not be as severe. Might be easier for an adult to not appreciate that they might have whooping cough and transmit it to, let's say, a younger person, exactly.

Speaker 2  02:08
And the other thing, though, is that that many teens and adults that come down with pertussis get this, this lingering cough, which greatly disturbs them, because it often can go on for a couple of months, and they feel like, you know, they're just hacking and hacking away without, you know, any obvious cause. And then they appear like, what? Why do I have this long, lasting cough? And you discover that they had actually Pertussis infection that appeared as a cold. And then, you know, they got this cough that seemed to never go away.

Speaker 3  02:40
So might be nagging for the adults, but I've seen some videos of kids coughing with the whooping cough, and it's unbearable to see kids gasping for air, and I think that those are the patient population that suffer the most.

Dr. Sean Kane  02:52
So Dr. Fennewald, can you tell us a little bit about the micro aspect of pertussis in terms of kind of how you get it? What are some of the things to know from a clinician's point of view regarding the microbiology of it.

Speaker 2  03:05
Okay, so Bordetella pertussis is a bacterium, so it causes respiratory tract infections in the pertussis strain that we're talking about only infects humans. Now, there's other pertussis strains out there, especially you may have heard about this in dogs there. There's a kennel cough in dogs, which sounds a lot like our infections, but it's not pertussis, it's a different Bordetella species. So we don't give it to the dogs and the dogs don't give it to us. The dogs have their vaccine, which we don't take, and we have our vaccine which they shouldn't take. Fair enough. So the interesting thing about Bordetella is that it commonly occurs despite vaccination. So there's usually about 10,000 or more cases per year in the United States. Over the last two years, and in 2012 they had an incredible 48,000, many in California.

Dr. Sean Kane  03:54
So it seems like that would be a rare circumstance, given that we have a treatable or preventable illness with the vaccine,

Speaker 2  04:02
and that's one of the issues we'll talk about today, that the vaccine is not as effective as we'd like it to be. So we have to be aware that even though patients have a history of vaccination, they can still get the infection. We have to realize too, that people that have the signs and symptoms can be a source for others that can get more serious disease, especially young infants.

Dr. Sean Kane  04:24
So how is this gram negative bacteria getting into the body? How is it transmitted? And then, how does it actually evade the host immune system to be able to get in and cause infection?

Speaker 2  04:34
Okay, so basically, it's transmitted by respiratory droplets, especially by coughing. But any talking is always going to provide some spread of this bacterium. So once it gets in, it has special proteins that attach to the ciliated cells that kind of line our respiratory tract, and it produces some toxin proteins. Now toxins are proteins that are going to be extracellular from the bacteria. They get out there and they have a long lasting action. So it's important to realize that in toxin mediated diseases, when we treat them with antibiotics while we destroy the bacteria, we don't destroy the toxins directly. So that helps explain, to some extent, why the symptoms are so long lasting, is that we have to wait to these toxins kind of dissipate on their own. Even though we've treated the patients with antibiotics, it may not relieve their symptoms for a while because of the toxin buildup. Okay. Now it's important to realize that usually the incubation period is about a week, seven to 10 days, but it can be up to three weeks or longer. So that means it's especially important for people that might be a source, especially for unvaccinated newborns. So that's one of the key things about thinking about vaccination and maybe prophylactic treatment that we'll get back to later. Now, in terms of being contagious, once they begin to develop symptoms, they're usually contagious for about three weeks, but then that they've been infected usually then by about four or five weeks.

Speaker 4  06:06
Okay. And how does that compare to some of the other bacteria that cause some of the more common infections?

Speaker 2  06:10
Actually, that's for many respiratory pathogens. That's That's pretty typical, okay, what's a little different is, is that, because the organism causes these long, lasting symptoms. If it's still hanging around, it can be transmitted later than than other like when, if you have somebody that has influenza, usually, once the fever and the sore throat have broken there, they might be contagious for just a couple more days now, now, since this disease has some vaccine and this has affected how the or how the cases have appeared. Let's look a little bit back in terms of history. So the first vaccine to pertussis was developed in the 1930s and it was mixed with components for diphtheria and tetanus, and at the first time, they used what's called a whole cell killed vaccine. In other words, they took the entire bacterium, killed it and then used those components for the vaccine, and that was a very effective vaccine, and that drove the number of cases of pertussis way down in the United States. So by the time we hit the 60s and the 70s, or fewer than 5000 cases a year. But people were noticing, or thought they were noticing, still kind of controversial, that there were a lot of side effects, especially to the whole killed component part. So starting in the late 1980s and really getting rolling in the 1990s they developed what's called an acellular vaccine. And we see this in the vaccines, because it has a small case A and then A P, so that stands for a cellular pertussis. And here they've taken some of the toxins, like pertussis toxins and the hemagglutinins that that are the binding factors, and use those purified components. But it looks like this vaccine isn't as effective, especially not as long lasting. Is the old vaccine that's still used in some third world countries, but not regularly used in the United States any longer. So now we've been seeing more and more people coming down with pertussis infections even though they've been vaccinated. Okay, so some people haven't get it when they haven't been vaccinated, but more and more people are getting it even if that they've been vaccinated, because it looks like the vaccine beneficial effect wanes. And I think as we look to the future, and I'll mention this in the summary at the end, we might see some new, improved vaccines that are under work, or they might be changing the schedule about how often we should be giving these vaccines out with an attempt to kind of make the people that are vaccinated more resistant to infection.

Speaker 3  08:38
And I just wanted to make it clear for our listener who are listening. Dr. fennan wall was talking about the older vaccine that was developed in 30s that was giving out a little bit more side effect. That's the big D, big T, big P, and the one that was developed a little later, which he mentioned with the little a, that's the big D, big T, little A and P, because there are a lot of acronyms, so I wanted to make sure that our listeners are keeping up with us,

Speaker 2  09:02
but you should also realize that from 2000 through 2012 there were 255th deaths from whooping cough in the US, and 221 of these were in infants younger than three months of age. So when we suspect that we have a Pertussis infection in that group, we have to be especially vigilant. That's the group that's most susceptible to severe disease or possible death.

Speaker 4  09:25
And we mentioned, you mentioned that some of the efficacy may be waning. Has there been any change in the number of individuals who have been getting vaccinated, or the rates of that? Because I know in the news there's been some concern about people maybe not getting all their routine vaccinations.

Speaker 2  09:38
That has somewhat been the case, but, but we still have a pretty high level of the vaccine, especially early on, almost all infants get this diphtheria, tetanus acellular pertussis vaccine. So they have a whole series. You start at two months of age, and then eventually you get one later on in a final in the series. Races of like, four to six years. But we'll talk about the second version the Pertussis vaccine that's given to older people a little later.

Dr. Sean Kane  10:09
I think, in thinking about again, the highest risk group for morbidity and mortality is that very young infant, so literally weeks to months old, as opposed to the adult. And when you look at who should be vaccinated, pregnant women is one of those groups, late in the second trimester and the third trimester to be vaccinated. And it seems like that's one of the drivers of targeting this group, is we want to provide some amount of vaccination for the child when they're born, until they get that first two month vaccine, to provide some protection,

Speaker 2  10:38
exactly, and if you remember by especially when you give if the mother's been vaccinated before, that another dose of this vaccine, which is recommended for every pregnancy, by the way, so even if they've had it during a previous pregnancy, want to do it. And the reason is, is that you want to have the body's immune system produce a lot of IgG immunoglobulin. Because that IgG immunoglobulin can cross through the placenta and be in the bloodstream of the newborn in birth, and that will protect it for several months, until the vaccine starts to be given out. So they'll they'll be partially protected that way, and then again, they can always get the Pertussis from their mom, who they'll almost always going to have close contact with so it's good that the mom doesn't come down with a fresh case of pertussis at the time. She's basically taking care of the newborn.

Speaker 3  11:28
That brings me to the other patient population that's important is the parents of infants and small children. They should also make sure that they have this vaccine available.

Speaker 2  11:38
And I should add, by the way, healthcare workers or any other daycare workers, or any other population that's going to be have close contact with newborns, fits into that category Absolutely

Dr. Sean Kane  11:49
So when thinking about the patient who comes in, whether it be a very young infant or maybe an adult, where they have coughing symptoms, maybe that are more chronic, or even in the infant, where We have the typical whooping sound. What kinds of things should we be thinking about from a diagnostic point of view to assess whether this patient may or may not have whooping cough, versus influenza versus some other infection?

Speaker 2  12:12
Let's divide this up into two groups. First, let's talk about infants and children, and then later on, we'll talk about teens and adults, because the presentations can be very different. Now, the symptoms in infants and children depend a little upon age and vaccination status, and it can be tricky if they've been vaccinated, because then they might just have prolonged coughing and they might not have these classic symptoms. But the classic symptoms in infant and children, this is the whooping cough. Is they first have what's called a catarrhal or cold-like phase, so they're not whooping at that stage. And it's hard to distinguish this from an ordinary garden variety cold. Okay, the patients usually don't have much of a fever, but they have a cough and they have a runny nose for a week or two. Often they won't be presented to the healthcare system at that time. You know, it's just like, okay, my kid's got a cold. So, well, okay, so then what usually happens is they keep on coughing, and then they sort of go to the whooping phase. So there's not much you can do or diagnose it successfully. Now, some people have noticed that if you get excessive tearing or redness in the eyes or the conjunctiva that can suggest pertussis, just only a slight suggestion. So at this stage, this early week or two stage, diagnosis is very, very difficult, unfortunate. That's unfortunate because that's the stage where antibiotic benefit is most clear cut. So the next phase is called the paroxysmal phase. And here what happens is the patients get increasing number and intensity of coughs. And there can be series or bouts of coughing that are called paroxysms. Sometimes these can be so severe, the patients start gagging. They'll struggle for breath. Sometimes they'll turn blue, which we call cyanotic, and there's very often post cough vomiting. So these kids that are have the severe illness are very unhappy campers, right? So they have these huge bouts of cough, they're turning blue, and then they're throwing up.

Dr. Sean Kane  14:05
I would imagine this is about the time that they're probably going into the health Yes,

Speaker 2  14:09
this is the time when you're you're going going to see them. Now, this is when you hear the whoops, which actually are the noise of four enforced inspiratory efforts with their narrowed airway, or trachea from the infection that's causing the whooping. And actually, in teens and adults, you don't get much whooping because they're bigger people with a wider airway or trachea, and you just don't get the same whooping effect, although the pathogenesis is pretty similar. So now you have these unhappy campers, right that are whooping it up, coughing, maybe their shortness of breath, they often they'll experience what's called apnea, or pausing and breathing, which kind of excites everybody in the room, and then you get the throwing up. Okay, so unfortunately, this can last two to six weeks, and sometimes even go up. To 10 weeks now, it's important to remember that that a lot of infants don't actually whoop. I mean, it's, you know, even though it's the characteristic sign of the disease, we have to be aware that, that if we don't cure the whoop, we don't rule it out, right? So we just have to be aware that some paroxysms of coughing, maybe the cyanosis and the vomiting that are most characteristic of the disease. It's important to realize that it's the infants within the first year that get the most serious disease. So what half of them wind up being hospitalized, mostly for problems with breathing and oxygenation.

Speaker 3  15:36
So those are more of the signs that you know parents will tell you, or you would notice when the child is in the clinic room. But then, are there any tests that we can run to identify that patient is really infected with pertussis?

Speaker 2  15:50
Okay, so actually, that the case definition, which is the criteria that's now, once again, we're talking about infants and children, is actually kind of a clinical definition. So it's a cough of more than two weeks with paroxysm whoops, or this post coughing, vomiting. So when you see that, then you kind of make a tentative clinical diagnosis of Pertussis infection. Now you can follow up with some lab diagnosis. The patients almost always have a very high white blood cell count or leukocytosis, you can also then, especially if it's early on, take a sample, send it for culture, or, more commonly, PCR, once again, culture, PCR more successful, and it's especially likely to fail if the patient's been having signs and symptoms for more than three weeks, and if it's been five weeks or more, it's hopeless.

Dr. Sean Kane  16:40
And what is the reason for that? Why is it so late in the course, we aren't very successful with PCR and culture, okay?

Speaker 2  16:46
And the answer is, it's relating to what's driving the disease. So by that time, in most patients, the immune system has already combating the bacteria pretty well, but the patients are suffering the symptoms due to these leftover toxin and other proteins. So those toxins are there. The toxin molecules themselves are unaffected by antibiotics, and so it's kind of, it's kind of at the end game, right at the infections over but the side effects or the consequences of the toxins aren't

Dr. Sean Kane  17:17
like you mentioned at this point. Our antibiotic therapy probably won't do a lot because we're really not having an issue with the actual bacteria. It's the byproducts of

Speaker 2  17:26
the bacteria. Exactly. The most usual complications you might see are pneumonia. So once again, this should be upper respiratory. So if we do a lung exam and there's abnormal lung findings, signs of consolidation, other things, then we have to realize that our patient doesn't just have an upper respiratory tract infection, but it's spread to their lungs. So it's always if we do that lung exam and there's bad things going on, especially in infants, then we know that they've got lung involvement. They might have a pneumonia, either due to the bacterium itself or to a secondary bacterial infection. So we need to realize that needs to be aggressively treated.

Speaker 3  18:02
Are there any other complications besides super infections that can be seen in these patients?

Speaker 2  18:07
Well, pneumonia is one. Apnea is commonly seen. I don't know if that's a complication or a side effect, where this patient's pause and breathing. That happens about two thirds of the cases. Very rarely will the patients have seizures or signs of brain dysfunction or encephalopathy. That's that's pretty unusual. So let's look at now we have our patient, and let's say they meet the case definition, which once again, coughing for two weeks with paroxysm whooping or vomiting in an infinite in a child. We want to treat them right then, even if we take a sample and send it for culture. PCR, we don't want to wait. We want to go ahead and treat Okay, once again, if it's after more than three or five weeks, there's no point in that. PCR, but one of the important things is symptom support, especially for infants, you want to be sure their fluid and nutrition status is good, because it's especially tricking if they've been vomiting a lot. Okay, easy to get dehydrated. Yeah, it's easy for them to get dehydrated. And remember, this disease can last many weeks, so they can they might need nutritional support, and either try NG tubes, which they don't like because they're vomiting and coughing, but, but, you know, the worst comes to worst. They they're going to get dead through an IV line. And of course, that would be something where the patient's hospitalized. Now, antibiotics can reduce the spread and reduce the symptoms. So once again, it should be empiric. We don't have to wait for the confirmed laboratory values. We want to start treating it. Now, the antibiotic of choice is a macrolide, and people, the two most commonly used ones are azithromycin and erythromycin. Now, erythromycin is the older antibiotic. There's a little more experience with that, but azithromycin seems to be just as effective. Remember, the big difference is that erythromycin causes a lot more upset stomachs. So patients don't like taking it. Sometimes they will complete treatments with erythromycin. For that reason. So that's why, clinically, many people say I'll just go with azithromycin. Although, if you'd ask in a study, does erythromycin work clinically and combating the infection as well as azithro, the answer is almost always the equally effective

Dr. Sean Kane  20:15
Dr. Fennewald, I can tell you, in the ICU, if we're treating, let's say, a community acquired pneumonia, it's always azithromycin. We actually only use erythromycin as a pro motility agent, so people who aren't tolerating, let's say, tube feeds, we actually don't use it for the antibiotic property. We use it to induce, basically, GI motility, maybe a little bit of diarrhea along with that.

Speaker 2  20:34
Yeah. Okay, so you know once again, so we're thinking, azithromycin. Okay, let's now change over and talk a bit about teens and adults. Now this is the tricky part, because their initial ones is just like the common cold, cough, run nose. This is technically the cattle phase, but you know, with teens and adults, not so much. Now, what happens is, after a week or two, the patient's other cold signs go away, except for this lingering cough. So they just get this dry hacking cough, which seems to go on for the longest period, right? Often a couple months, I've, I've had this and and you can amaze your relatives and friends that that if you, if you talk to them, and they have, they say, I've had this dry hacking cough for a couple months, and you say, Gee, did you? Did you start out with a cold it lasted about a week or two, and then it got better, but you had this coffee, that's exactly what happened. And it's and then they, unfortunately, they ask you the next question, like, what can I do about it? And I say, Not much at this stage, because you've been coughing for a month, so you just have to wait till the toxins dissipate in your body.

Dr. Sean Kane  21:37
That's the reason that I always take a Z pack every other month, just to make sure that I'm really avoiding any potential problems with Bordetella.

Speaker 2  21:45
Way to go. Dr. Kane, of course, he helps promote macrolide resistance among respiratory pathogens across the nation. Okay, so patients find this more annoying than really severe disease. I mean, occasionally somebody will have they'll break a rib because they're coughing so bad. But that's pretty unusual, is that complications. But it's important to realize that teens and adults can be a source of virus for infants and younger children. So that's why you always want to do that family history of who's in the household, who's been ill, so that you know you can kind of treat those patients, even if they're at the coughing phase, if they're in a household with especially infants in their first year. So once again, that diagnosis is based on clinical signs by the time you could do culture PCR, but by the time the patient's in there, they've almost always been coughing for a month or more, and it's not worth the effort. Now, once again, treatment would be the macrolides. It's best one begun early, but especially, we want to treat people that are health care workers, pregnant, people that are going to work with infants. And it's recommended for patients who have been coughing for up to eight weeks in that group, that high risk group, so we you know if they're not, if they're you know if they're just dealing with other healthy people, they don't really need antibiotics, especially after they've been coughing for a month or so, but if they're going to contact these high risk groups, we should go ahead and give it to them. And you know, if they're if they can easily avoid contact with young children until after they've been taking antibiotics for five days or so, that's best post exposure prophylaxis is recommended for individuals in close contacts of a confirmed case, in other words, where they got some culture, PCR result, close contacts would, of course, be healthcare workers, family members, even if they're vaccinated and once again, it's azithromycin.

Dr. Sean Kane  23:33
So what about the patients who have a macrolide allergy? Is there another drug class that we can reach for if we really have to give post exposure prophylaxis.

Speaker 2  23:41
Okay, I'm not sure about the post exposure prophylaxis. I know the backup drug for the treatment of the disease is trimethoprim sulfur. So trimethoprim sulfur is the backup. But once again, you have to remember, fair number of patients are going to have trimethoprim or especially sulfur allergies too. Let's talk a bit about the vaccines that are available for this organism. Who should get them and what? How should we do this? Okay, now we've mentioned this before. There's two types of vaccines, and they're used differently. So this is an acellular vaccine, which is composed of a denatured which means it's not biologically active, but still intact pertussis toxin and two or three other pertussis proteins that are purified. One of them is a hemagglutinin, but there's some others that are there, and there's two manufacturers for each type. So there's a total of four. So the one we talked about before, big D, big T, little a big P or D tap is given to infants and younger children starting at two months. So you go 246, another 115, to 18 months, and another one at four to six years. Now people have noticed that this is waning, and we're starting to get people that are nine and 10 years old coming down with the disease. So I wouldn't be too surprised that they changed this recommendation in the upcoming years. Okay, so. Still not done, but you know, we should realize that that's a group that's recognized as that increased risk. Now, the second vaccine that's available is big T for this is tetanus, little D and AP, and there's a couple different formulations, and this Tdap is given to teens and adults, and it's recommended at 11 or 12. So any teen who hasn't got it should get one as soon as possible to protect themselves, as well as infants. So the T, of course, stands for tetanus. So remember, we have every patient should get a tetanus booster every 10 years. So this Tdap vaccine can is got that tetanus booster with it, and they recommend that if you got a patient and they need a tetanus booster, or even if they don't, you should go ahead and give them this vaccine. So even if 10 years haven't expired yet, go ahead and give the vaccine. They said, maybe a little more redness at the site of injection. But that's about all. We mentioned this before. Pregnant women should get a dose of this Tdap vaccine during each pregnancy somewhere 27 to 36 weeks. And that's important, because that's different. That's different from the vaccine given to infants and children. And they recommend those over 65 should get this too. They recommend using a particular kind called boostrix by GSK as a little better than the other manufacturer's product. But they say if you got the patient there and you don't have boostrix, you give them the other one anyway, because otherwise they have a tendency to disappear and never return. So once again, it's important for healthcare workers to be immunized, because they're going to be a source. Anybody that's going to have special contact with infants and newborns, which are a special high risk group, should really get it to so in terms of future prospects, because of this waning of the immunity, I think we might either see, I know there's some new vaccines under development, so we might see some changes in that. We also might see some changes in the frequency of administration coming down the pike, and they say, Well, maybe we should get a Extra Booster at this time or that time to kind of drive these levels down, because, once again, we had 48,000 cases in 2012 we had 24,000 cases last year. That's kind of a high level for a vaccine disease, right? So most of our other vaccine control diseases are much less so. For example, diphtheria, there's been no US case in over 10 years. In fact, the case that came back, the person was unvaccinated and got it in Haiti. So, you know, I mean, a lot of the vaccines that are out there, you know, tetanus, we only get a handful of cases a year. We'd like to hopefully get to a situation someday where we can say, like with diphtheria, well, we haven't seen a pertussis case in the last 10 years in the United States, but the current vaccine formulation, it's not going to give us that level of protection.

Speaker 3  27:43
And what I would like to see in near future too, that the anti vaccine campaigns will learn, learn something from the recent rise in the numbers of pertussis infections or cases, and hopefully they'll get back to vaccinating not only against pertussis, but all the vaccine preventable diseases.

Speaker 4  27:59
And I think that's, I guess, illustrates a case where you know, even if you know you as an individual, think, Okay, I'm not going to get sick. I'm not going to suffer the main consequences. But do it for the kids. Idea that we're trying to also be aware of the fact that even if someone gets it and then may be able to find out that we're still the possibility of spreading it to other individuals who may be weaker or have less developed immune systems. Yeah.

Speaker 2  28:19
And I think most people would feel bad if they kissed the baby and gave the baby whooping cough. Okay, well, let's kind of think about this disease. Okay, so it's an upper respiratory disease. The high risk groups are infants, in other words, children up to the age of one, especially newborns, they get a disease that starts out as a cold, but then develops these bouts or paroxysms of coughing, post coughing, vomiting and maybe this whooping sound. And if you have those present, you should make a clinical diagnosis of Pertussis infection and begin treating with azithromycin only if the patient has been coughing for several months. Would you not treat it the patients we have to do careful lung exam. Be careful to watch out if they're in distress, because then they might have a pneumonia or they might need to go to the hospital. And we're going to treat with azithromycin, and we're going to treat other family members or contacts, so that if it's confirmed case, we can send off for laboratory confirmation, for culture, PCR, but it only works well if the patients are early on in the disease, and we we wouldn't want to make the false conclusion that our test results came back negative so they didn't have it, because this is so hard to get a positive result. We're not going to we're not going to be disturbed if and think our patient doesn't have a Pertussis infection, if their test results come back negative for teens and adults, and the disease is kind of a common cold with a long lingering cough that's more annoying than anything else, and treatment there is basically to prevent spread. Only early on in the disease is it going to have clinical benefit to the patient, and rarely. Will they appear for treatment if they've just been having a cold and a cough for a week or two, usually, by the time they show up, they've been coughing for a month or six weeks, in which case there's no benefit to them for antibiotic treatment, but we would want to prevent its spread.

Dr. Sean Kane  30:15
I think, from a drug safety point of view, it's worth kind of going over the history of the types of vaccines that were available and are currently available. So DTP, all capital letters, is the wholesale vaccine, yes, and we don't use that very much in the US, at least anymore, but

Speaker 2  30:31
people may have a history of gotten such a vaccine in Latin America or Africa or Asia. Then we

Dr. Sean Kane  30:37
have the DT, AP, with a being small, all the other letters being big. And this is what we give to infants as part of their routine pediatric vaccination schedule.

Speaker 2  30:47
That's correct, and that goes up to, usually about the age of four or six. Is the last the recommended dose. And once again, the CDC is a wonderful site, so that if you have a patient that's in this rate, that's missed a dose, they can help you do catch up vaccinations.

Dr. Sean Kane  31:02
Then the final vaccine that we have is the big T Little dap. And this is basically your booster for 11 to 12 year olds. And then adults who haven't received it yet, which could be part of their normal tenure tetanus booster, or it could be because they are pregnant, they're have exposure to an infant, something along those lines, or healthcare workers, or healthcare workers, absolutely. So you can probably appreciate very easily that if you're trying to get your Pertussis vaccine, there's kind of, you know, two to three different vaccines that that might mean with different amounts of the toxins in the vaccine. So as healthcare providers, it's really important that we're picking the right one for the right patient, because we don't want to give the wrong kind of vaccine to the wrong patient.

Speaker 3  31:42
And to summarize the treatment back, I mean, we're going to go with macrolides, like we mentioned, you know, the newer kind azithromycin is a little bit more tolerable when it comes to GI side effects. What works out good for the kids is that these formulations are also available in reconstitutable forms. And if the patients cannot tolerate macrolides, then we do have Bactrim option as well. Great.

Dr. Sean Kane  32:04
So Dr. Fennewald, I wanted to thank you again for showing up for the HelixTalk podcast. With that, I'm going to conclude I'm Dr. Kane, I'm Dr

Speaker 2  32:11
Schuman, I'm Dr. Patel. It was my pleasure to present as Dr. Fennewald,

Unknown Speaker  32:15
study hard students.

Narrator - Dr. Abel  32:19
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