eMedicine Specialties > Emergency Medicine > Infectious Diseases

Diphtheria: Follow-up

Author: Allysia M Guy, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Contributor Information and Disclosures

Updated: Oct 5, 2009

Follow-up

Further Inpatient Care

  • Provide supportive care, continuation of antibiotic treatment, and antipyretics for fever.
  • Closely observe for development of primary or secondary bacterial pneumonia.
  • Perform serial ECGs to detect cardiac abnormalities.
  • Provide physical therapy for patients with neurologic dysfunction.
  • Patients with endocarditis may require valve replacement.
  • Respiratory isolation may be indicated.
  • Monitor for serum sickness or hypersensitivity reactions in patients treated with DAT.

Further Outpatient Care

Complete age-appropriate immunization schedule. Treat all household and other close contacts with antibiotics as mentioned above. All suspected and confirmed carriers should be treated with erythromycin or penicillin for 14 days. Follow-up pharyngeal cultures must be obtained post treatment, confirming eradication of the bacterium.3

Inpatient & Outpatient Medications

  • Bronchodilators (may be beneficial for patients with mild respiratory symptoms)
  • Antipyretics
  • Antibiotics - Penicillin, erythromycin

Transfer

  • Intensive care unit admission is recommended for patients with impending respiratory compromise.
  • Isolation may be indicated.

Deterrence/Prevention

  • The Global Pertussis Initiative formed in 2001 is the task force working towards global immunizations and disease prevention in infants, adolescents, and adults for diphtheria, pertussis, and tetanus. 
  • The 4 forms of the diphtheria toxoid are as follows: DTaP, Tdap, DT, and Td. The childhood vaccination is called DTaP. Adult vaccination form is Tdap. These toxoid vaccinations are combined with acellular pertussis and tetanus vaccine.23
    • DTap is given at 2 months, 4 months, 6 months, 15-18 months, and 4-6 years. The uppercase D denotes the full strength of tetanus toxoid (7-8 Lf units).24
    • DT does not contain pertussis and is given to children who have had previous adverse reactions to the acellular pertussis incorporated vaccine.
    • Td is a vaccine for adolescents and adults given as a booster every 10 years or when an exposure has occurred. The lowercase d denotes reduced strength diphtheria toxoid (2.0-2.5 Lf units). It is given to those older than 7 years.25,17
    • Tdap is recommended for adolescents aged 11 or 12 years, or in place of one Td booster in older adolescents and adults aged 19-64 years. Boostrix is Tdap approved for adolescents aged 10-18, and Adacel is Tdap approved for those aged 19-64 years. Adacel is used for adult vaccination and is recommended by the CDC in the adult vaccination schedule since 2007.17 These immunization schedules have been modified due to trends of pertussis increasing in the adolescent and adult populations. Therefore, Tdap Boostrix and Adacel are now recommended in the immunization schedule for prevention of endemics associated with pertussis and diphtheria.26
  • Contact/respiratory isolation is indicated for prevention and deterrence of spreading the infection.

Complications

  • Respiratory failure due to pseudomembrane formation or aspiration, tissue edema, and necrosis
  • Cardiac - Myocarditis, cardiac dilatation and failure, mycotic aneurysm, endocarditis
  • Rhythm disturbances - Heart block, including AV dissociation and dysrhythmias
  • Secondary bacterial pneumonia
  • Cranial nerve dysfunction and peripheral neuropathy, total paralysis
  • Optic neuritis
  • Septicemia/shock (rare)
  • Septic arthritis, osteomyelitis (rare)
  • Metastasis of infection to distant sites such as spleen, myocardium, or CNS (rare)
  • Death

Prognosis

  • Cardiac involvement is associated with a very a poor prognosis, particularly AV and left bundle-branch blocks (mortality rate 60-90%).
  • Bacteremic disease carries a mortality rate of 30-40%.
  • High mortality rate is seen with invasive disease.
  • High mortality rates are seen in individuals younger than 5 years and in those older than 40 years.

Patient Education

  • Widespread awareness of the need for universal immunization is indicated.
  • Stress the importance of seeking medical attention in all cases of contact with suspected diphtheria cases.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize diphtheria and to promptly treat those infected and their close contacts
  • Failure to recognize cardiac dysrhythmias
  • Failure to secure the airway in the face of impending respiratory failure from obstructive pseudomembrane
  • Failure to admit patients to appropriate hospital setting
  • Failure to isolate infected patients or to identify and treat carriers
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Elzbieta Pilat, MD, Lorenzo Paladino, MD, and Malini K Singh, MD, to the development and writing of this article.

The authors and editors of eMedicine gratefully acknowledge the medical review of this article by Joseph U Becker, MD.



More on Diphtheria

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Differential Diagnoses & Workup: Diphtheria
Treatment & Medication: Diphtheria
Follow-up: Diphtheria
Multimedia: Diphtheria
References
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Further Reading

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Keywords

diphtheria, diphtheria symptoms, diphtheria causes, diphtheria treatment, diphtheria prevention, C diphtheriae, var , mitis, intermedius, gravis, diphtheria vaccine, diphtheria toxoid

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Contributor Information and Disclosures

Author

Allysia M Guy, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Barry J Sheridan, DO, Chief, Department of Emergency Medical Services, Brooke Army Medical Center
Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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