• Infant twins sustained severe circumoral and pharyngeal burns from a concentrated solution of benzalkonium (Zephiran) chloride prescribed for treatment of candidiasis. This report emphasizes the unnecessary hazard accompanying use of a potentially toxic drug—especially when prepared in error by the pharmacist—when a safer drug (nystatin) is available for treatment of oral candidiasis. Risks from use of a prescription drug for other than the intended patient are also highlighted by this episode of poisoning.
(Am J Dis Child 129:1208-1209, 1975)
Wilson JT, Burr IM. Benzalkonium Chloride Poisoning in Infant Twins. Am J Dis Child. 1975;129(10):1208-1209. doi:10.1001/archpedi.1975.02120470054015