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What is the best treatment for pertussis?
A short-term course of erythromycin, azithromycin, or clarithromycin is as effective as a long-term (2-week) erythromycin therapy in eradicating Bordetella pertussis from the nasopharynx (strength of recommendation [SOR]: A; based on one meta-analysis of randomized controlled trials [RCTs]). Evidence is insufficient to determine the benefit of antibiotic prophylaxis for pertussis contacts. However, due to high mortality and morbidity, prophylaxis is recommended for families who have an infant less than 6 months old (SOR: C; based on expert opinion).
Fewer doses and lower cost make compliance more likely
Marcia Warren, MD
Departments of Family and Community Medicine and Pediatrics, Baylor College of Medicine, Houston, Tex
I found this Clinical Inquiry on the treatment and prophylaxis of Bordetella pertussis invaluable as it addresses ease of dosing and cost, 2 things important in my pediatric community health practice with its inherent financial and social constraints. The alternatives suggested are easy to use and are as equally effective as the first-line therapy of erythromycin estolate, the long-term treatment recommended by the CDC and the AAP. These alternatives, clarithromycin and azithromycin, require either twice a day or a once a day dosing for 7 days or 3 days respectively, can be accommodated in busy households, thus promoting better compliance.
The cost of medication also relates to compliance. The cost difference between the first-line therapy and the alternative therapy is significant, and may be as much as $89. In an underinsured population, this out-of-pocket cost for the alternatives would prove prohibitive, resulting in decreased compliance. Where cost is not a great issue and concerns of compliance important, choosing the short-term treatment may be a preferable option. For the financially strapped, the 1-week regimen of erythromycin estolate would be preferable. The importance of counseling cannot be overstated in all dosing regimens, especially in those with a more difficult dosing schedule and in cases of prophylaxis in a household with an infant less than 6 months old.
Evidence summary
A 2005 Cochrane review of 11 RCTs and 1 quasi-randomized trial, with a total of 1720 adults and children, investigated several antibiotics for treatment and prophylaxis of pertussis. The outcome measures used to assess the efficacy of antibiotic treatment or prophylaxis vary between the trials and most of them did not report the immunization status of the participants. The Cochrane review included 1 meta-analysis of 3 studies with 252 participants, comparing azithromycin for 3 days, erythromycin estolate for 7 days, and clarithromycin for 7 days (short-term treatment) with erythromycin estolate for fourteen days (long-term treatment). The study showed equal efficacy in eradication of B pertussis from the nasopharynx of 99.2% to 97.7% (absolute risk reduction [ARR]=1.44%; 95% confidence interval [CI], –1.58 to 4.46). There were fewer side effects with the short-term treatment (32.1% vs 48.9%; ARR=16%; 95% CI, 7.84 to 25.84).1
A large, multicenter RCT of 477 children of 6 months to 16 years of age demonstrated that a 5-day treatment with azithromycin eradicated B pertussis from the nasopharynx as effectively as a 10-day course of erythromycin estolate.2 Similarly, trimethoprim/sulfamethoxazole proved as effective as erythromycin in eliminating B pertussis from the nasopharynx.
Although tetracycline and chloramphenicol are effective treatments for pertussis, they are not recommended because of their side effects.1 Six randomized trials failed to show any statistically significant difference between antibiotics and placebo on frequency and severity of cough or duration of pertussis disease.1 A randomized, placebo-controlled trial studied 300 household contacts of children with culture-positive pertussis. There was no statistically significant difference in either the frequency of pertussis disease or rate of positive cultures in household contacts between the erythromycin group (2.1%) and the placebo group (5.1%) (ARR=2.95%; 95% CI, –1.21 to 7.11).1
Another Cochrane review of 8 trials examined the effectiveness of the symptomatic treatment of cough in children and adults with pertussis. There were many problems with the methodological quality of these trials, including small sample sizes and poor reporting of the methods. Diphenhydramine, pertussis immunoglobulin, corticosteroids and salbutamol were compared with placebo. There were no statistically significant differences in coughing paroxysms, mean number of whoops per 24 hours or in duration of hospital stay between these interventions and placebo.3
Extracorporeal circulatory life support has been used to maintain perfusion for patients with severe disease. The mortality of these patients is very high.4 No RCTs of the effectiveness of this intervention has been performed.
TABLE
Antibiotics for treatment and prophylaxis of pertussis in children and adults
| FIRST-LINE THERAPY | DOSAGE FOR CHILDREN | DOSAGE FOR ADULTS | COST* |
|---|---|---|---|
| Erythromycin | 40-50 mg/kg orally or intravenously in 4 divided doses for 14 days5,7 | 1–2 g orally or intravenously in 4 divided doses for 14 days5,7 | 56 tabs (500 mg), $16 (generic) |
| ALTERNATIVE THERAPY IF PATIENT DOESN’T TOLERATE ERYTHROMYCIN | |||
| Clarithromycin | 15-20 mg/per kg orally divided every 12 hours for 10-14 days7or 14-15 mg/kg orally divided every 12 hours for 7 days1,5 | 500 mg orally every 12 hours for 7 days5 | 20 tabs (500 mg), $78 28 tabs (500 mg), $109 (generic) |
| Azithromycin | 10-12 mg/kg orally as single daily dose for 5 to 7 days5,7or 10 mg/kg orally single daily dose for 3 days1 | 500 mg orally once, then 250 daily on days 2-55,7 | 5 tabs (500 mg), $75 7 tabs (500 mg), $105 (no generic) |
| Trimethoprim-sulfamethoxazole | 8 mg of TMP, 40 mg/kg SMX per kg orally divided every 12 hours for 14 days5,7 | 160 mg of TMP, 800 SMX orally (1 tab DS) every 12 hours for 14 days5,7 | 28 tabs $8 (generic) |
| All these therapies have gastrointestinal side effects and risk for hypersensitivity reactions. | |||
| *Approximate retail price for adult dose. Available at: http://www.drugstore.com. Accessed on June 28, 2005. | |||
Recommendations from others
The Centers for Disease Control and Prevention recommends erythromycin for 14 days as a first choice for the treatment and prophylaxis of pertussis. Antibiotics should be started no later than 3 weeks after the onset of cough. Trimethoprim-sulfamethoxazole can be used as an alternative treatment for patients who do not tolerate erythromycin. Prophylaxis is recommended for all household and close contacts if pertussis is highly suspected.5
The American Academy of Pediatrics recommends the use of azithromycin and clarithromycin as an alternative treatment for patients who do not tolerate erythromycin. 5
A national consensus conference on pertussis held in Canada recommended prophylaxis for household contacts of an infant aged <1 year, pregnant women during the third trimester, and for vulnerable individuals who have had face-to-face exposure, or have shared confined air for >1 hour.6
1. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis) (Cochrane Review). Cochrane Database Syst Rev 2005;(1):CD004404.
2. Langley JM, Halperin SA, Boucher FD, Smith B. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) Azithromycin is as effective as and better tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics 2004;114:e96-101.
3. Pillay V, Swingler G. Symptomatic treatment of the cough in whooping cough (Cochrane Review). Cochrane Database Syst Rev 2003;(4):CD003257.
4. Williams GD, Numa A, Sokol J, Tobias V, Duffy BJ. ECLS in pertussis: does it have a role? Intensive Care Med 1998;24:1089-1092.
5. Guris D. Treatment and Chemoprophylaxis. Guidelines for the Control of Pertussis Outbreaks. Atlanta, Ga: Centers for Disease Control and Prevention, 2000. Last updated January 2005. Available at: www.cdc.gov/nip/publications/pertussis/guide.htm. Accessed on November 14, 2005.
6. National consensus conference on pertussis Can Commun Dis Rep 2003;29(Suppl 3):S1-S33 (English), S1-S36 (French). Last updated June 5, 2003. Available at: www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/29s3/index.html. Accessed on November 14, 2005.
7. Pertussis Information for Physicians: Diagnostic and Treatment Criteria Texas Department of Health Pertussis Treatment Guidelines. TDH Immunization Division; 2004;Last updated January 26, 2004. Available at: www.tdh.state.tx.us/immunize/html/pert_physician_txt.htm. Accessed on November 14, 2005.
A short-term course of erythromycin, azithromycin, or clarithromycin is as effective as a long-term (2-week) erythromycin therapy in eradicating Bordetella pertussis from the nasopharynx (strength of recommendation [SOR]: A; based on one meta-analysis of randomized controlled trials [RCTs]). Evidence is insufficient to determine the benefit of antibiotic prophylaxis for pertussis contacts. However, due to high mortality and morbidity, prophylaxis is recommended for families who have an infant less than 6 months old (SOR: C; based on expert opinion).
Fewer doses and lower cost make compliance more likely
Marcia Warren, MD
Departments of Family and Community Medicine and Pediatrics, Baylor College of Medicine, Houston, Tex
I found this Clinical Inquiry on the treatment and prophylaxis of Bordetella pertussis invaluable as it addresses ease of dosing and cost, 2 things important in my pediatric community health practice with its inherent financial and social constraints. The alternatives suggested are easy to use and are as equally effective as the first-line therapy of erythromycin estolate, the long-term treatment recommended by the CDC and the AAP. These alternatives, clarithromycin and azithromycin, require either twice a day or a once a day dosing for 7 days or 3 days respectively, can be accommodated in busy households, thus promoting better compliance.
The cost of medication also relates to compliance. The cost difference between the first-line therapy and the alternative therapy is significant, and may be as much as $89. In an underinsured population, this out-of-pocket cost for the alternatives would prove prohibitive, resulting in decreased compliance. Where cost is not a great issue and concerns of compliance important, choosing the short-term treatment may be a preferable option. For the financially strapped, the 1-week regimen of erythromycin estolate would be preferable. The importance of counseling cannot be overstated in all dosing regimens, especially in those with a more difficult dosing schedule and in cases of prophylaxis in a household with an infant less than 6 months old.
Evidence summary
A 2005 Cochrane review of 11 RCTs and 1 quasi-randomized trial, with a total of 1720 adults and children, investigated several antibiotics for treatment and prophylaxis of pertussis. The outcome measures used to assess the efficacy of antibiotic treatment or prophylaxis vary between the trials and most of them did not report the immunization status of the participants. The Cochrane review included 1 meta-analysis of 3 studies with 252 participants, comparing azithromycin for 3 days, erythromycin estolate for 7 days, and clarithromycin for 7 days (short-term treatment) with erythromycin estolate for fourteen days (long-term treatment). The study showed equal efficacy in eradication of B pertussis from the nasopharynx of 99.2% to 97.7% (absolute risk reduction [ARR]=1.44%; 95% confidence interval [CI], –1.58 to 4.46). There were fewer side effects with the short-term treatment (32.1% vs 48.9%; ARR=16%; 95% CI, 7.84 to 25.84).1
A large, multicenter RCT of 477 children of 6 months to 16 years of age demonstrated that a 5-day treatment with azithromycin eradicated B pertussis from the nasopharynx as effectively as a 10-day course of erythromycin estolate.2 Similarly, trimethoprim/sulfamethoxazole proved as effective as erythromycin in eliminating B pertussis from the nasopharynx.
Although tetracycline and chloramphenicol are effective treatments for pertussis, they are not recommended because of their side effects.1 Six randomized trials failed to show any statistically significant difference between antibiotics and placebo on frequency and severity of cough or duration of pertussis disease.1 A randomized, placebo-controlled trial studied 300 household contacts of children with culture-positive pertussis. There was no statistically significant difference in either the frequency of pertussis disease or rate of positive cultures in household contacts between the erythromycin group (2.1%) and the placebo group (5.1%) (ARR=2.95%; 95% CI, –1.21 to 7.11).1
Another Cochrane review of 8 trials examined the effectiveness of the symptomatic treatment of cough in children and adults with pertussis. There were many problems with the methodological quality of these trials, including small sample sizes and poor reporting of the methods. Diphenhydramine, pertussis immunoglobulin, corticosteroids and salbutamol were compared with placebo. There were no statistically significant differences in coughing paroxysms, mean number of whoops per 24 hours or in duration of hospital stay between these interventions and placebo.3
Extracorporeal circulatory life support has been used to maintain perfusion for patients with severe disease. The mortality of these patients is very high.4 No RCTs of the effectiveness of this intervention has been performed.
TABLE
Antibiotics for treatment and prophylaxis of pertussis in children and adults
| FIRST-LINE THERAPY | DOSAGE FOR CHILDREN | DOSAGE FOR ADULTS | COST* |
|---|---|---|---|
| Erythromycin | 40-50 mg/kg orally or intravenously in 4 divided doses for 14 days5,7 | 1–2 g orally or intravenously in 4 divided doses for 14 days5,7 | 56 tabs (500 mg), $16 (generic) |
| ALTERNATIVE THERAPY IF PATIENT DOESN’T TOLERATE ERYTHROMYCIN | |||
| Clarithromycin | 15-20 mg/per kg orally divided every 12 hours for 10-14 days7or 14-15 mg/kg orally divided every 12 hours for 7 days1,5 | 500 mg orally every 12 hours for 7 days5 | 20 tabs (500 mg), $78 28 tabs (500 mg), $109 (generic) |
| Azithromycin | 10-12 mg/kg orally as single daily dose for 5 to 7 days5,7or 10 mg/kg orally single daily dose for 3 days1 | 500 mg orally once, then 250 daily on days 2-55,7 | 5 tabs (500 mg), $75 7 tabs (500 mg), $105 (no generic) |
| Trimethoprim-sulfamethoxazole | 8 mg of TMP, 40 mg/kg SMX per kg orally divided every 12 hours for 14 days5,7 | 160 mg of TMP, 800 SMX orally (1 tab DS) every 12 hours for 14 days5,7 | 28 tabs $8 (generic) |
| All these therapies have gastrointestinal side effects and risk for hypersensitivity reactions. | |||
| *Approximate retail price for adult dose. Available at: http://www.drugstore.com. Accessed on June 28, 2005. | |||
Recommendations from others
The Centers for Disease Control and Prevention recommends erythromycin for 14 days as a first choice for the treatment and prophylaxis of pertussis. Antibiotics should be started no later than 3 weeks after the onset of cough. Trimethoprim-sulfamethoxazole can be used as an alternative treatment for patients who do not tolerate erythromycin. Prophylaxis is recommended for all household and close contacts if pertussis is highly suspected.5
The American Academy of Pediatrics recommends the use of azithromycin and clarithromycin as an alternative treatment for patients who do not tolerate erythromycin. 5
A national consensus conference on pertussis held in Canada recommended prophylaxis for household contacts of an infant aged <1 year, pregnant women during the third trimester, and for vulnerable individuals who have had face-to-face exposure, or have shared confined air for >1 hour.6
A short-term course of erythromycin, azithromycin, or clarithromycin is as effective as a long-term (2-week) erythromycin therapy in eradicating Bordetella pertussis from the nasopharynx (strength of recommendation [SOR]: A; based on one meta-analysis of randomized controlled trials [RCTs]). Evidence is insufficient to determine the benefit of antibiotic prophylaxis for pertussis contacts. However, due to high mortality and morbidity, prophylaxis is recommended for families who have an infant less than 6 months old (SOR: C; based on expert opinion).
Fewer doses and lower cost make compliance more likely
Marcia Warren, MD
Departments of Family and Community Medicine and Pediatrics, Baylor College of Medicine, Houston, Tex
I found this Clinical Inquiry on the treatment and prophylaxis of Bordetella pertussis invaluable as it addresses ease of dosing and cost, 2 things important in my pediatric community health practice with its inherent financial and social constraints. The alternatives suggested are easy to use and are as equally effective as the first-line therapy of erythromycin estolate, the long-term treatment recommended by the CDC and the AAP. These alternatives, clarithromycin and azithromycin, require either twice a day or a once a day dosing for 7 days or 3 days respectively, can be accommodated in busy households, thus promoting better compliance.
The cost of medication also relates to compliance. The cost difference between the first-line therapy and the alternative therapy is significant, and may be as much as $89. In an underinsured population, this out-of-pocket cost for the alternatives would prove prohibitive, resulting in decreased compliance. Where cost is not a great issue and concerns of compliance important, choosing the short-term treatment may be a preferable option. For the financially strapped, the 1-week regimen of erythromycin estolate would be preferable. The importance of counseling cannot be overstated in all dosing regimens, especially in those with a more difficult dosing schedule and in cases of prophylaxis in a household with an infant less than 6 months old.
Evidence summary
A 2005 Cochrane review of 11 RCTs and 1 quasi-randomized trial, with a total of 1720 adults and children, investigated several antibiotics for treatment and prophylaxis of pertussis. The outcome measures used to assess the efficacy of antibiotic treatment or prophylaxis vary between the trials and most of them did not report the immunization status of the participants. The Cochrane review included 1 meta-analysis of 3 studies with 252 participants, comparing azithromycin for 3 days, erythromycin estolate for 7 days, and clarithromycin for 7 days (short-term treatment) with erythromycin estolate for fourteen days (long-term treatment). The study showed equal efficacy in eradication of B pertussis from the nasopharynx of 99.2% to 97.7% (absolute risk reduction [ARR]=1.44%; 95% confidence interval [CI], –1.58 to 4.46). There were fewer side effects with the short-term treatment (32.1% vs 48.9%; ARR=16%; 95% CI, 7.84 to 25.84).1
A large, multicenter RCT of 477 children of 6 months to 16 years of age demonstrated that a 5-day treatment with azithromycin eradicated B pertussis from the nasopharynx as effectively as a 10-day course of erythromycin estolate.2 Similarly, trimethoprim/sulfamethoxazole proved as effective as erythromycin in eliminating B pertussis from the nasopharynx.
Although tetracycline and chloramphenicol are effective treatments for pertussis, they are not recommended because of their side effects.1 Six randomized trials failed to show any statistically significant difference between antibiotics and placebo on frequency and severity of cough or duration of pertussis disease.1 A randomized, placebo-controlled trial studied 300 household contacts of children with culture-positive pertussis. There was no statistically significant difference in either the frequency of pertussis disease or rate of positive cultures in household contacts between the erythromycin group (2.1%) and the placebo group (5.1%) (ARR=2.95%; 95% CI, –1.21 to 7.11).1
Another Cochrane review of 8 trials examined the effectiveness of the symptomatic treatment of cough in children and adults with pertussis. There were many problems with the methodological quality of these trials, including small sample sizes and poor reporting of the methods. Diphenhydramine, pertussis immunoglobulin, corticosteroids and salbutamol were compared with placebo. There were no statistically significant differences in coughing paroxysms, mean number of whoops per 24 hours or in duration of hospital stay between these interventions and placebo.3
Extracorporeal circulatory life support has been used to maintain perfusion for patients with severe disease. The mortality of these patients is very high.4 No RCTs of the effectiveness of this intervention has been performed.
TABLE
Antibiotics for treatment and prophylaxis of pertussis in children and adults
| FIRST-LINE THERAPY | DOSAGE FOR CHILDREN | DOSAGE FOR ADULTS | COST* |
|---|---|---|---|
| Erythromycin | 40-50 mg/kg orally or intravenously in 4 divided doses for 14 days5,7 | 1–2 g orally or intravenously in 4 divided doses for 14 days5,7 | 56 tabs (500 mg), $16 (generic) |
| ALTERNATIVE THERAPY IF PATIENT DOESN’T TOLERATE ERYTHROMYCIN | |||
| Clarithromycin | 15-20 mg/per kg orally divided every 12 hours for 10-14 days7or 14-15 mg/kg orally divided every 12 hours for 7 days1,5 | 500 mg orally every 12 hours for 7 days5 | 20 tabs (500 mg), $78 28 tabs (500 mg), $109 (generic) |
| Azithromycin | 10-12 mg/kg orally as single daily dose for 5 to 7 days5,7or 10 mg/kg orally single daily dose for 3 days1 | 500 mg orally once, then 250 daily on days 2-55,7 | 5 tabs (500 mg), $75 7 tabs (500 mg), $105 (no generic) |
| Trimethoprim-sulfamethoxazole | 8 mg of TMP, 40 mg/kg SMX per kg orally divided every 12 hours for 14 days5,7 | 160 mg of TMP, 800 SMX orally (1 tab DS) every 12 hours for 14 days5,7 | 28 tabs $8 (generic) |
| All these therapies have gastrointestinal side effects and risk for hypersensitivity reactions. | |||
| *Approximate retail price for adult dose. Available at: http://www.drugstore.com. Accessed on June 28, 2005. | |||
Recommendations from others
The Centers for Disease Control and Prevention recommends erythromycin for 14 days as a first choice for the treatment and prophylaxis of pertussis. Antibiotics should be started no later than 3 weeks after the onset of cough. Trimethoprim-sulfamethoxazole can be used as an alternative treatment for patients who do not tolerate erythromycin. Prophylaxis is recommended for all household and close contacts if pertussis is highly suspected.5
The American Academy of Pediatrics recommends the use of azithromycin and clarithromycin as an alternative treatment for patients who do not tolerate erythromycin. 5
A national consensus conference on pertussis held in Canada recommended prophylaxis for household contacts of an infant aged <1 year, pregnant women during the third trimester, and for vulnerable individuals who have had face-to-face exposure, or have shared confined air for >1 hour.6
1. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis) (Cochrane Review). Cochrane Database Syst Rev 2005;(1):CD004404.
2. Langley JM, Halperin SA, Boucher FD, Smith B. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) Azithromycin is as effective as and better tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics 2004;114:e96-101.
3. Pillay V, Swingler G. Symptomatic treatment of the cough in whooping cough (Cochrane Review). Cochrane Database Syst Rev 2003;(4):CD003257.
4. Williams GD, Numa A, Sokol J, Tobias V, Duffy BJ. ECLS in pertussis: does it have a role? Intensive Care Med 1998;24:1089-1092.
5. Guris D. Treatment and Chemoprophylaxis. Guidelines for the Control of Pertussis Outbreaks. Atlanta, Ga: Centers for Disease Control and Prevention, 2000. Last updated January 2005. Available at: www.cdc.gov/nip/publications/pertussis/guide.htm. Accessed on November 14, 2005.
6. National consensus conference on pertussis Can Commun Dis Rep 2003;29(Suppl 3):S1-S33 (English), S1-S36 (French). Last updated June 5, 2003. Available at: www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/29s3/index.html. Accessed on November 14, 2005.
7. Pertussis Information for Physicians: Diagnostic and Treatment Criteria Texas Department of Health Pertussis Treatment Guidelines. TDH Immunization Division; 2004;Last updated January 26, 2004. Available at: www.tdh.state.tx.us/immunize/html/pert_physician_txt.htm. Accessed on November 14, 2005.
1. Altunaiji S, Kukuruzovic R, Curtis N, Massie J. Antibiotics for whooping cough (pertussis) (Cochrane Review). Cochrane Database Syst Rev 2005;(1):CD004404.
2. Langley JM, Halperin SA, Boucher FD, Smith B. Pediatric Investigators Collaborative Network on Infections in Canada (PICNIC) Azithromycin is as effective as and better tolerated than erythromycin estolate for the treatment of pertussis. Pediatrics 2004;114:e96-101.
3. Pillay V, Swingler G. Symptomatic treatment of the cough in whooping cough (Cochrane Review). Cochrane Database Syst Rev 2003;(4):CD003257.
4. Williams GD, Numa A, Sokol J, Tobias V, Duffy BJ. ECLS in pertussis: does it have a role? Intensive Care Med 1998;24:1089-1092.
5. Guris D. Treatment and Chemoprophylaxis. Guidelines for the Control of Pertussis Outbreaks. Atlanta, Ga: Centers for Disease Control and Prevention, 2000. Last updated January 2005. Available at: www.cdc.gov/nip/publications/pertussis/guide.htm. Accessed on November 14, 2005.
6. National consensus conference on pertussis Can Commun Dis Rep 2003;29(Suppl 3):S1-S33 (English), S1-S36 (French). Last updated June 5, 2003. Available at: www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/29s3/index.html. Accessed on November 14, 2005.
7. Pertussis Information for Physicians: Diagnostic and Treatment Criteria Texas Department of Health Pertussis Treatment Guidelines. TDH Immunization Division; 2004;Last updated January 26, 2004. Available at: www.tdh.state.tx.us/immunize/html/pert_physician_txt.htm. Accessed on November 14, 2005.
Evidence-based answers from the Family Physicians Inquiries Network