DIPHTHE RIA

An acute, highly contagious toxin-mediated infection caused by Corynebacterium diphtheriae, a grampositive, aerobic rod that usu. infects the respiratory tract; primarily the tonsils, nasopharynx, & larynx,

C. diphtheriae

Infected humans

INCUBATION PERIOD: Usu. 2-5 days, possibly longer

Weakened Humans

CHAIN OF INFECTIO N

Discharges from mucous membranes of nose and nasopharynx, skin, & other lesions

Respiratory Integumentary

Airborne droplets, direct contact, contaminated fomites, & raw milk

HUMAN ANATOMY & PHYSIOLOGY (Upper Respiratory Tract)

RISK FACTOR S

PREDISPOSING RISK FACTORS: Poor sanitation Crowded living conditions Limited access to healthcare Lack of periodic booster immunizations

PRECIPITATING RISK FACTORS: Direct contact with infected person, carrier, or contaminated articles Use of contaminated objects from diphtheria-infected people Ingestion of unpasteurizeed milk

PATHOGEN ESIS

RISK FACTORS Colonizes in the mucosal surface & multiply Bacteria release a toxin Diphtheria toxin is absorbed to the mucous membranes Destruction of epithelium (tissue necrosis)

Embedded in exuding fibrin & red & white cells Psuedomembrane formation

NASAL:

DIPHTHE RIA

Resembles common cold; serosanguineous mucopurulent nasal discharge w/o constitutional symptoms May be frank epistaxis

TONSILLAR/ PHARYNGEAL: Thick, patchy, smooth, adherent white/ grayish memrane over the mucous Low-grade fever Malaise Anorexia Headache Sore throat Malodorous breath Dysphagia Swollen & tender cervical lymph nodes (lymphadenitis) possibly pronounced w/ warm & swollen neck (bulls neck) Increased weak pulse

LARYNGEAL: Fever Hoarseness Rasping cough (and other symptoms similar to croup) W/ or w/o other sings listed (potential airway obstruction) Restlessness Apprehensive Dyspneic (suprasternal) retractions Tachypnea Cyanosis Stridor

CUTANEOUS: Skin lesions resemble impetigo

CLINICAL MANIFESTATIO NS

Headache

Lowgrade fever

Anorexia

Thick, patchy, smooth, adherent white/ grayish memrane over the mucous

Swollen & tender cervical lymph nodes (lymphadenitis) possibly pronounced w/ warm & swollen neck (bulls neck)

Skin lesions resemble impetigo

SIMPLE CRITICAL THINKING: As a nurse caring for a patient with diphtheria, what should be kept at bedside?

Suction equipment, Tracheostomy tray and Epinephrine

DIAGN OSIS

Examination showing the characterisic membrane and a throat culture, or culture of other suspect lesions growing C. diptheriae in an enzymelinked immunosorbent asssay( E:LISA) or the Elek test (toxigencity test), confirm the diagnosis. Gramstain or immunofluorescent antibody stains may also be used; these tests yield results

THERAPEUTIC MANAGEMENT

 Diphtheria antitoxin (IM; usu. IV); preceded by skin or conjunctival test to r/o sensitivity to horse serum  Antibiotics (penicillin/ erythromycin)  CBR (for prevention of myocarditis)  Tracheostomy for airway obstruction

COMPLICATI ONS

o Thrombocytopenia o Neurologic involvement (primarily affecting motor fibers but possibly also sensory neurons) o Renal involvement o Pulmonary involvement (bronchopneumonia) o Myocarditis (2nd wk.) o Neuritis

NURSING CONSIDERATI ONS

Preventing Spread of Infection

Maintain and stress the need for strict isolation in hospital Teach proper disposal of nasopharyngeal secretions Maintain infection precautions

SIMPLE CRITICAL THINKING: When can we say a patient is free from C. diphtheriae?

Maintain infection precautions until after three consecutive negative cultures at least 24 hours apart, with the first culture being at least 24 hours after the completion of antimicrobial therapy.

SIMPLE CRITICAL THINKING: How about those whom the patient had close contact with?

Nasopharyngeal and throat cultures are also obtained from all close contacts. Symptomatic clients are isolated and treated until two negative throat cultures are obtained. Asymptomatic disease carriers are confined to home until at least 3 days of antibiotic therapy have been completed. Booster shots are given to people who were immunized 5 or more years previously. Unimmunized contacts are treated with immunization and antibiotics. All contacts, including hospital personnel, receive tetanus and diphtheria toxoid

Monitoring and Preventing Complications Administer complete care to maintain bed rest Observe respiration for signs of obstruction (esp. in laryngeal diphtheria) and be ready to give immediate life support, including intubation & tracheostomy

 Be alert for signs of myocarditis, such as development of heart murmurs or ECG changes. Ventricular fibrillation is a common cause of sudden death in diphtheria patients Watch for signs of shock, w/c can develop suddenly If neuritis develops, tell the patient its usually transient. Be aware that peripheral neuritis may not develop until 2 to 3

Patient Comfort Limit the diet to liquids and soft foods Throat irrigation and fluids

Collaborative Nursing Considerations

Have patient participated in sensitivity testing; have epinephrine (1:1,000) readily available Give drugs as ordered. After giving antitoxin or penicillin, be alert for anaphylaxis; keep epinephrine 1: 1,000 and resuscitation handy. In patients who receive erythromycin, watch for thrombophlebitis

 Use suctioning as needed Administer humidified 02 if prescribed Serial ECGs should be performed twice weekly for 4 to 6 weeks to watch for myocarditis Obtain cultures as ordered

Prevention
Stress the need for childhood immunizations to all parents. Report all cases of diphtheria to local public health authorities.

SIMPLE RECALL: What is the scheduling of diphtheria immunizati on based from EPI?

At 6 weeks, infants are given 0.5 mL of DPT vaccine IM at upper outer portion of the thigh. This immunization has 3 doses with 4 weeks interval..

Diphtheria infection doesnt confer immunity, therefore diphtheria immunization should be given during convalescence.

RELATED JOURNAL S

Effect of a single tetanus-diphtheria tetanusvaccine dose on the immunity of elderly people in So Paulo, Brazil
Abstract Epidemiological data regarding tetanus and diphtheria immunity in elderly people in Brazil are scarce. During the First National Immunization Campaign for the Elderly in Brazil in April 1999, 98 individuals (median age: 84 years) received one tetanus-dyphtheria (Td) vaccine dose (Butantan Institute, lot number 9808079/G). Inclusion criteria were elderly individuals without a history of severe immunosuppressive disease, acute infectious disease or use of immunomodulators. Blood samples were collected immediately before the vaccine and 30 days later. Serum was separated and stored at -20oC until analysis. Tetanus and diphtheria antibodies were measured by the double-antigen ELISA test. Tetanus and diphtheria antibody concentrations lower than 0.01 IU/mL were considered to indicate the absence of protection, between 0.01 and 0.09 IU/mL were considered to indicate basic immunity, and values of 0.1 IU/mL or higher were considered to indicate full protection. Before vaccination, 18% of the individuals were susceptible to diphtheria and 94% were susceptible to tetanus. After one Td dose, 78% became fully immune to diphtheria, 13% attained basic immunity, and 9% were still susceptible to the disease. In contrast, 79% remained susceptible to tetanus,

Although one Td dose increases immunity to diphtheria in many elderly people who live in Brazil, a complete vaccination series appears to be necessary for the prevention of tetanus. Key words: Elderly, Tetanus, Diphtheria, Immunization

Fin.