DOH NCP Infectious Disease

Diphtheria Handout
by Rachelle Mae Dimayuga, RN

Causative Agent:
Corynebacterium Diphtheriae
an aerobic gram positive
bacillus
It is characterized by the
production of a systematic toxin
and an adherent false
membrane lining the mucous
membrane of the throat
(Mosby, 2006)
Reservoir:
Asymptomatic/symptomatic
human
Mode of Transmission: Direct Droplet (Discharges from
mucous membranes of nose
and nasopharynx)
Portals of Entry: Mucous
membrane (i.e. nasal, tonsillar,
pharyngeal, laryngeal)
Incubation Period: 2-5 days
(range 1-10 days) It is
communicable for 2-6 weeks
without antibiotic treatment
Once apt antibiotics are
administered, it is usually no
longer contagious after 48
hours.
Disease Classification
* The disease can involve almost any
mucous membrane. Diphtheria can
be classified depending on the
anatomic site of disease.

Anterior Nasal Diphtheria

The onset is
indistinguishable from that
of the common cold. It is
characterized by a
mucopurulent nasal
discharge which may
become blood-tinged and
it may present a white
membrane on the nasal
septum.
The disease is usually mild
due to poor systemic
absorption of toxin in this
location and can be
terminated rapidly by
diphtheria antitoxin and
antibiotics.
Pharyngeal and Tonsillar
Diphtheria
The most common site of
diphtheria infection and
usually the sites that is
associated with substantial
systemic absorption of
toxin.
Within 2-3 days, a
pseudomembrane forms
and extends, varying in
size from a small patch on
the tonsils to covering
most of the soft palate.
Laryngeal Diphtheria
It can either be an
extension of the
pharyngeal form or can
involve only this site
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 Cutaneous Diphtheria
A disease characterized by
indolent, non-healing
ulcers covered with a gray
membrane. It may also be
manifested by a scaling
rash or by ulcers with
clearly demarcated edges
and membrane.
It begins as a vesicle or
pustule filled with strawcolored fluid which breaks
down quickly. The lesion
progresses to form a
punched-out ulcer, single
or multiple with slightly
curved and elevated
margins
The lesions are painful and
may be covered with an
adhering eschar (dark
pseudomembrane) during
the first 1-2 weeks. Then
the lesion becomes
anesthetic, and the
pseudomembrane falls
away, leaving a
hemorrhagic base,
sometimes with serous or
serosanguinous exudate
oozing from it.
The surrounding tissue is
edematous and pink,
purple, or livid in color and
may show blisters or
bullae.

These ulcers are usually

co-infected with
Staphylococcus aureus
and Group A Streptococci.
This form of the disease is
often associated with
homeless persons and
poor inner-city dwellers

Signs and Symptoms

Sore throat
Anorexia
Low-grade fever
Mucosal erythema
Pseudomembrane
Hoarseness
Dysphagia
Bull-neck appearance (Cervical
edema)
Dyspnea
Respiratory stridor or wheezing
Cough
Parameters for Admission
Suspected cases show:
o Pharyngitis, nasopharyngitis, tonsillitis,
laryngitis, tracheitis (or
any combination of these),
absent or low-grade fever
o Presence of grayish
adherent
pseudomembrane
o Membrane bleeds if
manipulated or dislodged

 Probable cases present:

(Suspect case above +1 or
more of the following)
o Stridor
o Bull-neck (cervical edema)
o Toxic circulatory collapse
o Acute renal insufficiency
o Sub-mucosal or
subcutaneous petechiae
o Myocarditis
o Recently returned (<2
weeks) from travel to area
with endemic diphtheria
o Recent contact (<2
weeks) with confirmed
diphtheria case or carrier
o Recent contact (<2
weeks) with visitor from
area with endemic
diphtheria
o Immunization status:
Incomplete, no
vaccination of any
DTaP/DT/Tdap/Td shot
within past 10 years, or no
history of immunization at
all
Diagnostic Laboratories
- Isolation of C. diphtheriae by
culture
o Gold standard diagnostic
confirmatory in diphtheria
o Specimens should be
taken from the nose or
nasopharynx, throat or
even obtaining a piece of
the membrane.

o Specimen should be
obtained as soon as
diphtheria is suspected
and even if antibiotics
were started
o Result will be more
accurate if done prior to
administration of
antibiotics
- PCR (Polymerase Chain
Reaction)

PCR allows for

detection of the regulatory
gene for toxin production
and the diphtheria toxin
gene. Note that it only
detects and demonstrates
the diphtheria toxin gene
and not the production of
diphtheria toxin
Specimens needed can
either be from nasal and
throat swabs, biopsy
tissue, or pieces from the
membrane
Transportation of the
specimens should be in a
sterile empty container
with cold packs or in silica
gel sachets
A positive PCR test in the
absence of a positive
culture does not meet the
laboratory criteria for
classifying a case as
confirmed diphtheria
- Eleks Test
3

 This test is done to

determine whether the
organisms produce
diphtheria toxin.
Demonstration of toxin
production confirms a case
as a diphtheria
This method is particularly
applicable to epidemic
situations

Medications
Antibiotics
Ideally, treatment should be started
after obtaining specimens needed to
culture C. diphtheriae. Persons with
suspected diphtheria should also
receive antibiotics to eradicate
carriage of C. diphtheriae, to limit
transmission and to halt further
production of diphtheria toxin. 48
hours after antibiotics are instituted,
diphtheria is usually not contagious.
In addition, to confirm complete
eradication of the organism, two
consecutive negative cultures should
be documented after completion of
antibiotic regimen.
Erythromycin (Oral)
40mg/kg/day; maximum of
2g/day for 14 days
Mode of action: Inhibits
bacterial growth by

blocking dissociation of
peptidyl tRNA from
ribosomes, causing RNA
dependent protein
synthesis to arrest.
Some studies suggest that
this drug may be better at
eradication of the carrier
state
Nursing Responsibility:
Absorption may be
reduced by food
intake, therefore this
medicine is best
taken with a glass of
water and half an
hour before meals.
Penicillin G (IM or IV)
300,000 U/day for those
weighing 10kg or less and
600,000 U/day for those
weighing >10kg for 14
days
Mode of action: Interferes
with cell wall mucopeptide
synthesis during active
multiplication resulting in
bactericidal activity
against susceptible
microorganisms.
Studies show that it has an
effective treatment for
systemic diphtheria.
However, resistant strains
from penicillin-treated
carriers has been reported.
Nursing Responsibility:
4

 Obtain history
regarding allergies
with Pencillins
When administrating
to infants and small
children through IM,
administer on vastus
lateralis
When administering
intravenously, give at
a slow and steady
rate
Diphtheria Antitoxin
Prompt administration of DAT is
the pillar of treatment in cases
of suspected diphtheria. This
should be given without waiting
for laboratory confirmation of a
diagnosis
It does not neutralize toxin that
is already fixed to tissues, but it
will neutralize circulating
unbound toxin and prevent
progression of disease
The patient must be tested for
sensitivity before antitoxin is
given. First, through scratch,
prick, or puncture skin test,
followed by an intradermal test
if skin test is negative. This
should be done in order as skin
test is thought to be safe while
the intradermal test has been
reported to cause fatal
anaphylactic reactions. (See

Tables 1 & 2 in case of a (+)skin

test)
Recommended DAT dosage
ranges are:
Pharyngeal or laryngeal
disease with 2 days
duration: 20,000-40,000 U
Nasopharyngeal disease:
40,000-60,000 U
Systemic disease of 3
days duration or any
patient with cervical
lymphadenopathy: 80,000100,000 U
Dosage is constant regardless
of age and weight
Nursing responsibilities:
Antitoxin should be
warmed to 32-340C before
injection. Warming above
recommended
temperature should be
avoided because DAT
proteins will denature.
As ordered by a physician,
give the entire treatment
dose of antitoxin
intravenously in a single
administration diluted in
250-500 normal saline,
administrated slowly over
2-4 hours.
It may be given through IM
in mild to moderate cases.
Special precaution should
be taken during skin
testing and administration
5

of DAT. Gather necessary

medications, equipment,
and staff should be ready
in case of severe
anaphylactic reactions to
maintain the patency of
airway.
Diphtheria Toxoid
There are four vaccines used to
prevent diphtheria: DTaP, Tdap,
DT and Td. Each of these
vaccines prevents diphtheria
and tetanus; DTaP and Tdap
also help prevent pertussis.
DTaP and DT are given to
children younger than 7 years
old, while Tdap and Td are
given to older children and
adults.
Since diphtheria does not
always confer immunity, an
age-appropriate vaccine
containing diphtheria toxoid
should be given during
convalescence period.
Immunization schedule for
infants in the Philippines:
DTaP (Diphtheria, Tetanus
and Pertussis) 6th, 10th,
and 14th week
Booster doses:
4-6 years old (DTaP)
11-12 years old (Tdap)
Every 10 years thereafter
(Td)
Nursing Responsibility:

Vaccines should be
maintained in a
temperature of 2-80C
Administer vaccine
through IM
Provide health teachings
and emphasize the need to
complete vaccination
Nursing Management
Isolate patient, wear apt PPE,
implement a strict handwashing
policy to patient, guardians and
visitors, instruct watchers to
wear mask, don gloves when
handling patients discharges,
and instill proper disposal of
discharges.
To maintain a patent airway,
place patient on semi to high
Fowlers position, instruct to do
deep breathing with pursed lips,
suction secretions as needed,
administer oxygen as ordered
by the physician, monitor
respiration and oxygen
saturation, and refer
accordingly. Once an artificial
airway has been established,
provide daily tracheostomy care
using sterile technique, change
dressings as needed, and
suction secretions as needed
with proper PPE.
To prevent aspiration, keep
patient in semi to high Fowlers
position and instruct patient to
6

maintain on NPO as ordered or

Discharge Plan
strictly follow the physicians
Medication: Instruct patient
prescribed diet as ordered with
and significant others on the
aspiration precautions.
right time, dose and route of
Strictly monitor intake and
their home medications. Provide
output, provide infusion pump
written instructions, insist to
to regulate and monitor IV fluid,
recap the medications to be
and assess color of urine.
taken and when, and emphasize
To prevent and promptly detect
the need to complete the
myocarditis caused by
treatment.
diphtheria, monitor pulse rate
Environment: Put emphasis on
and blood pressure, assess for
the need to keep home clean
any irregularities on rhythm and
and well-ventilated, most
rate, perform serial ECG as
importantly prior to patients
ordered, and if with any
arrival at home. Advise to
abnormality, recheck and refer
refrain from accepting visitors
to physician.
for a week.
Put on complete bed rest,
Treatment: Instruct patient
refrain from doing strenuous
and family members to receive
activities, may do ADLs on bed
vaccination against diphtheria
with rests in between.
from the nearest health center
and complete the prophylaxis.
Advice to avoid strenuous
Discharge Parameters
activities, do ADLs as tolerated
Completion of antibiotic
and have adequate rests.
treatment
Health Teaching: Instruct
Two negative cultures on C.
patient to avoid crowded areas,
diphtheriae after 14 days of
and educate parents regarding
antibiotic treatment
the need to immunize.
Total removal of
Outpatient Referral: Instruct
pseudomembrane
patient and significant others to
Normal tracing of ECG
come back in their scheduled
Normal findings on chest x-ray,
follow-up visit, emphasize the
clear breath sounds, respiration
need to seek consult with a
rate and oxygen saturation
cardiologist, nephrologist, and
within the normal range
7

neurologist to further assess for

complications
Diet: May have soft diet then
progress to diet as tolerated.
References:
Diphtheria Assessment Checklist. (2016, July 26). Retrieved from CDC:
http://www.cdc.gov/diphtheria/downloads/dip-cklist-diag.pdf

Diphtheria Infection. (2016, July 26). Retrieved from CDC: http://www.cdc.gov/diphtheria/

Efstratiou, A., Engler, K., Mazurova, I., & Gluskevich, T. (2000). Current Approaches to the Laboratory
Diagnosis of Diphtheria. The Journal of Infectious Disease, 138-145.
Hadfield, T., McEvoy, P., Polotsky, Y., Tzinserling, V., & Yakovlev, A. (2000). The Pathology of Diphtheria.
The Journal of Infectious Disease, 116-120.
Lo, B. M. (n.d.). Diphtheria. Retrieved from Medscape: http://emedicine.medscape.com/article/782051overview
Opinel, A., & Gachelin, G. (2010). French 19th century contributions to the development of treatments
for diphtheria. Retrieved from The James Lind Library:
http://www.jameslindlibrary.org/articles/french-19th-century-contributions-to-thedevelopment-of-treatments-for-diphtheria/
WHO | Diphtheria. (2016, July 20). Retrieved from WHO: http://www.who.int/topics/diphtheria/en/