Pediatric Diphtheria Treatment & Management
- Author: Cem S Demirci, MD; Chief Editor: Russell W Steele, MD more...
Critical care needs and complications must be addressed. Mechanical ventilation may be inevitable because the combination of airway obstruction by the diphtheritic membrane and peripharyngeal edema pose a fatality risk in patients with diphtheria.
Specific antitoxin is the mainstay of therapy and should be administered on the basis of clinical diagnosis because it neutralizes free toxin only. Efficacy diminishes with elapsing time after the onset of mucocutaneous symptoms. Only an equine preparation is available in the United States from Connaught Laboratories (Swiftwater, Pennsylvania) or from the CDC.
Antitoxin is administered once at an empiric dose based on the degree of toxicity, site and size of the membrane, and duration of illness. Most authorities prefer the intravenous route, with infusion over 30-60 minutes. Antitoxin is probably of no value for local manifestations of cutaneous diphtheria, but its use is prudent because toxic sequelae can occur. Commercially available immunoglobulin preparations for intravenous use contain antibodies to diphtheria toxin; their use for therapy of diphtheria is not proved or approved. Antitoxin is not recommended for asymptomatic carriers.
When an asymptomatic carrier is identified, the following steps are taken:
Antimicrobial prophylaxis is administered for 7-10 days.
An age-appropriate preparation of diphtheria toxoid is immediately administered if the patient has not received a booster injection within 1 year.
Individuals are placed in strict isolation (respiratory tract colonization) or contact isolation (cutaneous colonization only) until at least 2 subsequent cultures taken 24 hours apart after cessation of therapy demonstrate negative results.
Repeat cultures are performed at a minimum of 2 weeks after completion of therapy in patients and carriers; if results are positive, an additional 10-day course of oral erythromycin should be administered and follow-up cultures performed.
Antimicrobial agents fail to eradicate carrier status in 100% of individuals.
Otolaryngeal assessment is needed in patients with severe respiratory or neurologic complications or as part of critical care.
See the list below:
Cardiologist: Elevation of serum aspartate aminotransferase concentrations closely parallels the severity of myonecrosis. In electrocardiographic tracings, a prolonged PR interval, changes in the ST-T wave, and single or progressive cardiac dysrhythmias can occur, such as first-degree, second-degree, and third-degree heart block, atrioventricular dissociation, and ventricular tachycardia. Toxic cardiomyopathy and myocarditis are also complications that need to be evaluated and monitored by a pediatric cardiologist.
Neurologist: Neurologic complications parallel the extent of primary infection and are multiphasic in onset.
- Hypesthesia and local paralysis of the soft palate occur commonly. Weakness of the posterior pharyngeal, laryngeal, and facial nerves may follow, causing a nasal tone in the voice, difficulty in swallowing, and risk of death from aspiration.
- Cranial neuropathies characteristically occur in the fifth week and lead to oculomotor and ciliary paralysis, which manifest as strabismus, blurred vision, or difficulty with accommodation.
- Symmetric polyneuropathy begins within 10 days to 3 months after oropharyngeal infection and principally causes motor function deficit with diminished deep tendon reflexes.
- Proximal muscle weakness of the extremities progressing distally and, more commonly, distal weakness progressing proximally are described. Clinical and cerebrospinal fluid (CSF) findings in distal weakness are indistinguishable from findings of polyneuropathy of Landry-Guillain-Barré syndrome. Paralysis of the diaphragm can ensue.
Lai J, Fay KE, Bocchini JA. Update on childhood and adolescent immunizations: selected review of US recommendations and literature: part 2. Curr Opin Pediatr. 2011 Aug. 23(4):470-81. [Medline].
Dittmann S, Wharton M, Vitek C, et al. Successful control of epidemic diphtheria in the states of the Former Union of Soviet Socialist Republics: lessons learned. J Infect Dis. 2000 Feb. 181 Suppl 1:S10-22. [Medline].
Golaz A, Hardy IR, Strebel P, et al. Epidemic diphtheria in the Newly Independent States of the Former Soviet Union: implications for diphtheria control in the United States. J Infect Dis. 2000 Feb. 181 Suppl 1:S237-43. [Medline].
Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countries. Cochrane Database Syst Rev. 2011 Jul 6. CD008145. [Medline].
Swart EM, van Gageldonk PG, de Melker HE, van der Klis FR, Berbers GA, Mollema L. Long-Term Protection against Diphtheria in the Netherlands after 50 Years of Vaccination: Results from a Seroepidemiological Study. PLoS One. 2016. 11 (2):e0148605. [Medline].
Lurie P, Stafford H, Tran P. Fatal respiratory diphtheria in a U.S. traveler to Haiti--Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep. 2004 Jan 9. 52(53):1285-6. [Medline].
Januszkiewicz-Lewandowska D, Gowin E, Bocian J, Zając-Spychała O, Małecka I, Stryczyńska-Kazubska J, et al. Vaccine-Derived Immunity in Children With Cancer-Analysis of Anti-Tetanus and Anti-Diphtheria Antibodies Changes after Completion of Antineoplastic Therapy. Pediatr Blood Cancer. 2015 Dec. 62 (12):2108-13. [Medline].
Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006 Dec 15. 55:1-37. [Medline]. [Full Text].
Murphy TV, Slade BA, Broder KR, et al. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008 May 30. 57:1-51. [Medline]. [Full Text].
Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged 1111111111MMWR Morb Mortal Wkly Rep</i>. 2011 Oct 21. 60:1424-6. [Medline].
Additional recommendations for use of tetanus toxoid, reduced-content diphtheria toxoid, and acellular pertussis vaccine (Tdap). Pediatrics. 2011 Oct. 128(4):809-12. [Medline].
Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 Mar 24. 55(RR-3):1-34. [Medline]. [Full Text].
AAP. Diphtheria. Committee on Infectious Disease. The Red Book. 26th ed. American Academy of Pediatrics; 2003. 263-6.
Boughton B. Diphtheria Vaccine Administered in the Thigh Appears Safer. Medscape Medical News. Jan 14 2013. Available at http://www.medscape.com/viewarticle/777585. Accessed: March 18, 2013.
Chen RT, Broome CV, Weinstein RA, et al. Diphtheria in the United States, 1971-81. Am J Public Health. 1985 Dec. 75(12):1393-7. [Medline].
Farizo KM, Strebel PM, Chen RT, et al. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation, and control. Clin Infect Dis. 1993 Jan. 16(1):59-68. [Medline].
Galazka A. The changing epidemiology of diphtheria in the vaccine era. J Infect Dis. 2000 Feb. 181 Suppl 1:S2-9. [Medline].
Hodes HL. Diphtheria. Pediatr Clin North Am. 1979 May. 26(2):445-59. [Medline].
Jackson LA, Peterson D, Nelson JC, Marcy SM, Naleway AL, Nordin JD, et al. Vaccination site and risk of local reactions in children 1 through 6 years of age. Pediatrics. 2013 Feb. 131(2):283-9. [Medline].
Kulkarni PS, Sapru A, Bavdekar A, Naik S, Patwardhan M, Barde P, et al. Immunogenicity of two diphtheria-tetanus-whole cell pertussis-hepatitis B vaccines in infants: A comparative trial. Hum Vaccin. 2011 Sep 1. 7(9):941-4. [Medline].
Lewis LS, Hardy I, Strebel P, et al. Assessment of vaccination coverage among adults 30-49 years of age following a mass diphtheria vaccination campaign: Ukraine, April 1995. J Infect Dis. 2000 Feb. 181 Suppl 1:S232-6. [Medline].
Long SS. Diphtheria. Behrman RE, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. WB Saunders Co; 2000. 817-20.
Long SS, Pickering LK, Prober CG. Corynebacterium diphtheriae. Principles and Practice of Pediatric Infectious Diseases. Churchill Livingstone; 1997. 861.
Lubran MM. Bacterial toxins. Ann Clin Lab Sci. 1988 Jan-Feb. 18(1):58-71. [Medline].
Mattos-Guaraldi AL, Moreira LO, Damasco PV. Diphtheria Remains a Threat to Health in the Developing World- An Overview. Mem Inst Oswaldo Cruz, Rio de Janeiro. 2003. 98(8):987-93.
McMillan JA, Feigin RD. Diphtheria. McMillan JA, Warshaw JB, DeAngelis CD, eds. Oski's Pediatrics: Principles and Practice. 3rd ed. Wolters Kluwer Co; 1999. 961-4.
Prospero E, Raffo M, Bagnoli M, et al. Diphtheria: epidemiological update and review of prevention and control strategies. Eur J Epidemiol. 1997 Jul. 13(5):527-34. [Medline].