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Am J Dis Child. 1975 Oct;129(10):1208-9.

Benzalkonium chloride poisoning in infant twins.

Abstract

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.

[Indexed for MEDLINE]

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