Diphtheria with Diffuse Neck Swelling, Symptom Duration ≥ 48 Hours, or Severe Disease
This protocol addresses diphtheria in patients presenting with one or more features that define a more serious or established disease state: diffuse swelling of the neck, disease of any site with symptoms lasting 48 hours or longer, or severe disease characterised by respiratory distress or haemodynamic instability (shock).
These presentations — including the characteristic diffuse neck swelling ("bull neck"), symptom duration of ≥ 48 hours, respiratory distress, or shock — indicate severe or extensive disease requiring prompt, structured management.
Management centres on a macrolide antibiotic given in combination with diphtheria antitoxin (DAT), with the antibiotic initiated without delay. The full regimen — including specific antibiotic selection, dosing by age and weight, administration route, and antitoxin dosing — is detailed in the structured protocol.
References
- Diffuse swelling of the neck.
- Any disease ≥ 48 hours.
- Severe disease (respiratory distress, shock).
- Severe/extensive disease: duration of 3 or more days, or diffuse neck swelling (the so called "bull neck"), or respiratory distress, or hemodynamic instability.
- In patients with suspected or confirmed diphtheria, WHO recommends using macrolide antibiotics (azithromycin, erythromycin) in preference to penicillin antibiotics [Strong recommendation, low certainty evidence].
- Antibiotics should be administered alongside DAT and should not be delayed.
- In patients with suspected or confirmed symptomatic diphtheria, WHO suggests administration of a single dose of diphtheria antitoxin with choice of dose based on disease severity and time since symptom onset, in comparison with a fixed dose for all patients [Conditional recommendation, very low certainty evidence].