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. [4]
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, especially with previous prosthetic valves. However, some evidence suggests that antibiotic therapy with a beta-lactam with or without an aminoglycoside may be adequate in treating endocarditis with either a native or prosthetic valve. [23]
Respiratory isolation may be indicated.
Monitor for serum sickness or hypersensitivity reactions in patients treated with DAT.
Inpatient & Outpatient Medications
The following medications may be necessary:
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Bronchodilators (may be beneficial for patients with mild respiratory symptoms)
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Antipyretics
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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. Children < 7 years receive DTaP or DT. The uppercase D denotes the full strength of diphtheria toxoid. [27] Older children and adults receive Tdap and Td. These toxoid vaccinations are combined with acellular pertussis and tetanus vaccine. [26]
DTap is given at 2 months, 4 months, 6 months, 15-18 months, and 4-6 years.
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. [28]
Tdap is recommended for adolescents aged 11-12 years, if not contraindicated, or in place of one Td booster in older adolescents and adults aged 19 years and older. [29] Adults > 65 years may receive either Tdap vaccine formulation (Boostrix as per label or Adacel according to reports); Boostrix and Adacel are approved for adolescents aged 10 years and older; Adacel is Tdap approved for those aged 10-64 years.
The CDC’s Advisory Committee for Immunization Practices recently recommended that pregnant patients should receive a single dose of Tdap dose during pregnancy, preferably during the early part of 27-36 weeks gestation, regardless of previous vaccination status. [30] This allows maternal antibodies to pass on to the fetus, giving protection for the first few months of life.
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. [29, 31, 32]
Contact/respiratory isolation is indicated for prevention and deterrence of spreading the infection.
Complications
Complications may include the following:
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Respiratory failure due to pseudomembrane formation or aspiration, tissue edema, and necrosis
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Cardiac - Myocarditis, cardiac dilatation and failure, mycotic aneurysm, endocarditis
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Rhythm disturbances - Heart block, including AV dissociation and dysrhythmias
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Secondary bacterial pneumonia
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Cranial nerve dysfunction and peripheral neuropathy, total paralysis
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Septicemia/shock (rare)
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Septic arthritis, osteomyelitis (rare)
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Metastasis of infection to distant sites such as spleen, myocardium, or CNS (rare)
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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.
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The characteristic thick membrane of diphtheria infection in the posterior pharynx.
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Cervical edema and cervical lymphadenopathy from diphtheria infection produce a bull's neck appearance in this child. Source: Public Domain www.immunize.org/images/ca.d/ipcd1861/img0002.htm.
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Photomicrograph depicts a number of gram-positive Corynebacterium diphtheriae bacteria, which had been stained using the methylene blue technique. The specimen was taken from a Pai's slant culture.
