Prehospital Care
Careful assessment of airway patency and cardiovascular stability. Patients should be transported to the nearest hospital.
Emergency Department Care
Treatment of diphtheria should be initiated even before confirmatory tests are completed due to the high potential for mortality and morbidity.
Isolate all cases promptly and use universal and droplet precautions to limit the number of possible contacts.
Secure definite airway for patients with impending respiratory compromise or the presence of laryngeal membrane. Early airway management allows access for mechanical removal of tracheobronchial membranes and prevents the risk for sudden asphyxia through aspiration. Consider involving ENT or operating room personnel for intubation and securing of airway if there is suspicion for loss of the airway or respiratory failure.
Maintain close monitoring of cardiac activity for early detection of rhythm abnormalities. Initiate electrical pacing for clinically significant conduction disturbance and provide pharmacologic intervention for arrhythmias or for heart failure.
Provide 2 large-bore IVs for patients with a toxic appearance; provide invasive monitoring and aggressive resuscitation for patients with septicemia.
Initiate prompt antibiotic coverage (erythromycin or penicillin) for eradication of organisms, thus limiting the amount of toxin production. Antibiotics hasten recovery and prevent the spread of the disease to other individuals.
Neutralize the toxin as soon as diphtheria is suspected. Diphtheria antitoxin is a horse-derived hyperimmune antiserum that neutralizes circulating toxin prior to its entry into the cells. It prevents the progression of symptoms. The dose and route of administration (IV vs IM) are dependent on the severity of the disease. This antitoxin must be obtained directly from the Centers for Disease Control and Prevention (CDC) through an Investigational New Drug (IND) protocol. The patient must be tested for sensitivity to the antitoxin before it is given. Antitoxin is only available in the United States. For more information regarding acquisition, see the CDC website for diphtheria antitoxin.
Diphtheria disease does not confer immunity; thus, initiation or completion of immunization with diphtheria toxoid is necessary.
Obtain throat and nasal swabs from persons in close contact with the suspected diphtheria victim; administer age-appropriate diphtheria booster.
Initiate antibiotic therapy with erythromycin or penicillin for chemoprophylaxis in a patient with suspected exposure. Throat cultures should be repeated in 2 weeks after treatment.
Consultations
The following consultations may be necessary:
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Centers for Disease Control and Prevention (CDC), to report the case and to secure help in obtaining antitoxin and as well for testing and typing of toxin if indicated
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Infectious disease service and neurology
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Cardiology, for assistance in managing cardiac complications
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Critical care service, for admission into the ICU
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ENT/anesthesia, for airway control
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Surgery, for assistance in obtaining a surgical airway if needed in a nonemergent fashion
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Pulmonary, for bronchoscopy for pseudomembrane removal or obstruction
Prevention
The widespread use of the diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine in childhood has significantly decreased the incidence of diphtheria. However, childhood immunity wanes, requiring an updated booster vaccine. The CDC recommends either Tdap, or Td at least every 10 years to maintain immunity. [7]
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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.
