October 1975

Benzalkonium Chloride Poisoning in Infant Twins

Author Affiliations

From the divisions of pediatric clinical pharmacology and pediatric endocrinology, departments of pediatrics, pharmacology, and physiology, Vanderbilt University School of Medicine, Nashville, Tenn.

Am J Dis Child. 1975;129(10):1208-1209. doi:10.1001/archpedi.1975.02120470054015

• 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)