I hate being made to feel as though I’m backed into a corner.  Very little will get my dander up as to have a patient accost me with words, such as, “well, my FAMILY’S doctor did so-and-so for THEM...so I don’t understand why YOU can’t do it for ME.” Even if...said doctor prescribed “x” medication without justification, sound judgment, or...just maybe...my patient may have misinterpreted the entire scenario that his/her family relayed to that provider...and the “truth” is really nothing of the sort.

Hearsay...a blessedly NOT-so-wonderful thing.  And how powerless I feel in the face of hearing about it from MY patient’s lips.

This past holiday week, I was on-call on Christmas Eve and Day.  Late on Christmas Eve morning, a patient called to tell me that her nephew was diagnosed with pertussis.  He had been at their house earlier in the week, around her parents.  After being seen by his pediatrician and tested, several days later, lab testing confirmed pertussis.  SHE had been away and NOT exposed to him at all, but came home one day after he had been at the home.  Her nephew’s parents were given azithromycin as prophylactic treatment.  Apparently, HER parents were also given a Z-pack as well, as they had contact with the nephew and his parents.

She called me, stating that SHE wanted a Z-pack as well..."because, you know, MY PARENTS got the antibiotic.” (from their PCP) Mind you, no one had a cough, rhinorrhea, etc.  Her parents were all set to host a huge party on Christmas Eve, and she wanted my advice as to whether or not everyone would be ”absolutely, 100% safe”--risk-free from contracting pertussis, as the child had been in the house two days prior to the day of the party.

Well...I looked at the current guidelines on cdc.gov as I spoke with her (see below).  She had not been in direct contact with her nephew, so I didn’t feel that her getting a Z-pack was necessary.  No, I would not guarantee 100% that everyone would be “safe,” and if they were really concerned, they should cancel the party.

After a twenty minute conversation, we hung up.  No prescription.  She verbalized her agreement.

Several hours later, she called back.  She was going to be with friend in a few days who was 9-months pregnant.  No, she did not know if the friend had been vaccinated.  She REALLY, REALLY felt that she needed that Z-pack..."you know, after all,” she intoned, “her FAMILY’S DOCTOR had given ALL of them Z-packs, so why in the world did SHE not get one?” I could tell by the conversation that her family was putting her up to the repeat phone call.

I was tired.  My family from out-of-town was visiting, after my not seeing them for seven months.  I was wrapping gifts for the first time...and after several weeks of fatigue with getting ready to be “bought out” by the hospital, all I wanted to do is relax.  I’d already spoken with her at length.  I admit...I’m not proud of the fact that I thought, “why in the world do I need to rehash this?  Haven’t I already spent 20 minutes talking to and educating her about this?”

No...I was being called AGAIN...because someone else prescribed a medication.  True...THOSE people had direct contact with the nephew.  I explained that to her.  It didn’t matter.

So...given my fatigue and being tired of trying to educate her yet again...I admit it.  I gave in.  I called in the Z-pack.  With a caveat.

I asked her to please hold off and ONLY take it if she started with rhinorrhea and a cough.  After all...per the guidelines, one has up to 3 weeks to take the medication.  I didn’t think that was unreasonable.

Do I think that she waited?  I doubt it.  Did I compromise my ethics?  Well, I guess that depends on your school of thought.

I spoke with my own PCP this week.  He, too, has been inundated with calls about patients with “exposure” to pertussis, as well as meningitis.  He has held off on treatment for non-contact individuals, but admits that it is extremely difficult when patients are constantly calling and “in-your-face” about it.  Such as, a call from an administrator across campus, who demands Cipro because “patient A” had meningitis in a dorm room about half a mile away...and there was NO chance of contact.  Or when a university hands out meds like candy to the entire campus..."just in case.”

I get it...really, I do.  Meningitis can be fatal.  Who can recall every last step that a person may have had, thus exposing potentially hundreds of people?  In my patient’s case, she was OUT OF TOWN and had no exposure to said individual.

Then I look at the statistics about antibiotic resistance and shudder.  How many of us providers, unknowingly OR unwillingly...or not...contribute to that?

All we can do is continually educate...educate...educate.  And occasionally, prescribe that Z-pack and hope it’s the “right” thing to do.

For current guidelines on pertussis treatment:

http://www.cdc.gov/pertussis/clinical/treatment.html

Administer a course of antibiotics to close contacts within 3 weeks of exposure, especially in high-risk settings; same doses as in treatment schedule.

Post-exposure prophylaxis. A macrolide can be administered as prophylaxis for close contacts of a person with pertussis if the person has no contraindication to its use. The decision to administer post-exposure chemo prophylaxis is made after considering the infectiousness of the patient and the intensity of the exposure, the potential consequences of severe pertussis in the contact, and possibilities for secondary exposure of persons at high risk from the contact (e.g., infants aged <12 months). For post-exposure prophylaxis, the benefits of administering an antimicrobial agent to reduce the risk for pertussis and its complications should be weighed against the potential adverse effects of the drug. Administration of post-exposure prophylaxis to asymptomatic household contacts within 21 days of onset of cough in the index patient can prevent symptomatic infection. Coughing (symptomatic) household members of a pertussis patient should be treated as if they have pertussis. Because severe and sometimes fatal pertussis-related complications occur in infants aged <12 months, especially among infants aged <4 months, post-exposure prophylaxis should be administered in exposure settings that include infants aged <12 months or women in the third trimester of pregnancy. The recommended antimicrobial agents and dosing regimens for post-exposure prophylaxis are the same as those for treatment of pertussis (Table 4). 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm?s_cid=rr5414a1_e

Kim

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