The complications of severe diphtheria will be local (due to respiratory obstruction) and systemic, mainly myocarditis and neuritis (due to toxin). All patients with a strong clinical suspicion of diphtheria should be treated immediately with antibiotics and antitoxin. Erythromycin 500 mg intravenously every 6 h or penicillin G (benzylpenicillin) 600 to 1200 mg intravenously every 6 h are the recommended regimens to prevent further toxin production; very few strains are currently resistant to erythromycin.

Recommendations on dose of antitoxin are reached on the basis of clinical experience and the assumption that the duration of disease and extent of membrane formation are a guide to the toxic burden. The dose range is from 10 000 IU for tonsillar diphtheria of short duration, through 40 000 to 60 000 IU for pharyngeal disease, to 100 000 to 150 000 IU for extensive disease of duration 3 days or more. The antitoxin can be given intramuscularly or intravenously. In severe disease at least some of the dose should be given intravenously. Antitoxin should be preceded by an intracutaneous test dose. Occasional anaphylactic reactions occur, and the drugs necessary to treat anaphylaxis should be drawn up. Conventional wisdom (but no trials) favors bed rest. Steroids do not help to reduce the incidence of myocarditis or neuritis.

Where there is any evidence of respiratory obstruction in laryngeal diphtheria, tracheostomy should be performed as an emergency procedure without delay. The main role of critical care is in managing the cardiac complications which occur in diphtheria myocarditis, which has a 50 per cent mortality. The early indications are ECG abnormalities with ST changes, ectopics, arrhythmias, and heart block. Mortality in heart block is very high, even with cardiac pacing. Congestive cardiac failure and valvular incompetence may occur as the ventricles dilate. Neurological complications, including respiratory and laryngeal paralysis, may occur many weeks after the infection has been eliminated and the patient seems to be recovering.

Once they have recovered, patients should receive active immunization against diphtheria.

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