Removal of membrane by direct laryngoscopy or bronchoscopy may be necessary to prevent or alleviate airway obstruction. Diphtheria antitoxin must be delivered promptly to prevent myocarditis, neuritis, or death. DT is present in infected individuals in a circulating, or unbound form, a form bound to the surface of cells, and also internalized into the cytoplasm. The antitoxin is able to neutralize circulating toxin and may affect the bound form to some degree, but has no effect on the internalized fraction of toxin. Due to the delay in bacteriologic confirmation of diphtheria, the decision to treat with antitoxin is determined by clinical and epidemiological evidence and must be considered whenever there is a membrane present in the throat or nares. The antitoxin is of equine origin, and an intradermal skin test can be performed to evaluate the possibility of horse serum sensitivity. If this test is negative, the total dose of antitoxin should be administered. This total dose varies, depending on the site of diphtheria involvement, ranging from 10,000 to 20,000 units for anterior nasal diphtheria to increasing doses for tonsillar, pharyngeal, laryngeal, or nasopharyngeal diphtheria, up to 80,000 to 120,000 units for patients with brawny cervical edema (4). The antitoxin is available via the Centers for Disease Control and Prevention (CDC) as an investigational agent at this time in the United States.

Penicillin and erythromycin are effective agents for treatment of diphtheria, with penicillin being the preferred agent, for a duration of 14 days. Antibacterial therapy is not a substitute for antitoxin treatment. Bed rest should be enforced for 12 days due to the risk for myocarditis (5). Sudden death can be caused by myocardial failure from excessive activity. Palatal and pharyngeal paralysis from neuritis may cause aspiration, requiring gastric or duodenal feedings, and diaphragmatic paralysis may require mechanical ventilation. For patients with laryngeal diphtheria, treatment with intubation or tracheostomy also may be required. In addition to administration of antitoxin and antibiotics, strict isolation procedures are required to limit propagation of the disease.

Treatment of the carrier state of diphtheria may include a single dose of intramuscular penicillin G or a 7- to 10-day course of oral erythromycin, followed by nasopharyngeal cultures at 14 days to confirm eradication of the carrier state. Persistence of the carrier state after the initial course of antibiotics is followed by an additional 10-day course of erythromycin and repeated cultures, in addition to evaluation for a nasal foreign body.

Immunization with diphtheria toxoid is the only effective means of primary prevention. The primary series is four doses of diphtheria toxoid (given with tetanus toxoid and pertussis vaccine) at 2, 4, 6, and 15 to 18 months; a preschool booster dose is given at ages 4 to 6 years. Thereafter, tetanus and diphtheria toxoid for adults (Td) boosters should be given as part of the adolescent immunization visit (i.e., between 11 and 13 years of age), followed by doses administered every 10 years.

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