TETANUS

Tetanus & Clostridium tetani

■ Hippocrates described the disease as far back as 5th
century BC
1884
1889
Antonio Carle &
Giorgio Rattone 1924
First C. tetani
found the cause of isolation by
the disease Tetanus toxoid
Kitasato vaccine developed
Shibasaburo by P. Descombay
Tetanus Epidemiology

Tetanus was
reported from
14 province;
Death number
reached 53,8%*

*Profil Kesehatan Indonesia Tahun 2013. Kementerian Kesehatan Republik Indonesia

 TETANUS
PATHOPHYSIOLOGY
Clostridium tetani and its transmission
■ Gram-positive bacteria , anaerobic rod, develop terminal
spore (drumstick appearance)
■ Commonly found in soil, saliva, dust and manure
■ Tetanus is not passed from person to person
■ Transmission via entry of C. Tetani into injured skin or wounds

Tetanolysin
Unknown

Tetanospasmin
“Most potent toxins
known”
Min. human lethal
dose: 2.5 ng/KgBW
Tetanus Toxin Mechanism of Action
 TETANUS
CLINICAL MANIFESTATIONS
Clinical Manifestations
■ Incubation period: 3-21 days
■ Types of disease
1. Generalized (80%)
2. Localized
3. Cephalic
4. Neonatal
Generalized Tetanus
■ Descending pattern, highest fatality rate
■ Muscle spasms:
– Trismus or lockjaw, facial spasms or risus sardonicus, stiffness of
neck, opisthotonus, diffculty of swallowing, general muscle rigidity
– “Reflex spasms”  Elicited by noise, light, or touch
■ Sympathetic overactivity:
– High fever, profuse sweating, hypertension, episodic tachycardia or
arrythmias
■ Symptoms may continue to four weeks, complete
recovery may take months
■ Respiratory failure and cardiovascular instability  DEATH
Trismus

Risus
sardonicus

Opisthotonus
Localized Tetanus
■ Uncommon form, lowest fatality rate (1%)
■ Persistent contraction of muscles in the area of skin
injury

Cephalic Tetanus
■ Rarest form (0.9-3% of the cases)
■ Form of localized disease that affects cranial nerves
■ Happen after ear infections or head injuries
■ May progress to a more generalized form
Neonatal Tetanus / Tetanus Neonatorum

■ Form of generalized tetanus that occurs in

newborns, born to mothers whom have not been
vaccinated
■ Occurs through infection of the unhealed umbilical
stump cut with a non-sterile instrument
■ Typical symptoms similar to generalized tetanus
 TETANUS DIAGNOSIS
AND SEVERITY GRADING
Tetanus Diagnosis
Tetanus is a clinical diagnosis

■ Currently no blood tests for diagnosing tetanus

■ “Spatula test”
■ Electromyograms may show continuous discharge
of motor units and shortening or absence of the
silent interval normally seen after an action
potential
■ Muscle enzyme levels may be raised
Differential Diagnosis
■ Seizure of other etiology
■ Brain infections (meningitis & encephalitis)
■ Drug-induced dystonias
■ Trismus due to dental infection
■ Strychnine poisoning
■ Malignant neuroleptic syndrome
■ Stiff-person syndrome
 Tetanus
Severity Score

Score Mortality
<8 6.3%
≧8 53%
Phillips
Score

Score Grading
<9 Mild
9-16 Moderate
>16 Severe
 Dakar
Score

Score Grading Mortality

0-1 Mild <10%
2-3 Moderate 10-20%
4 Severe 20-40%
5-6 Very severe >50%
Ablett
Score
TETANUS MANAGEMENT
Treatment
Tetanus is a medical emergency, requiring hospitalization

1. Wound management
2. Supportive care
3. Prevention and vaccination
Wound Management
1. Assess type of wound
– Wounds should be considered dirty if contaminated with dirt, soil,
feces, or saliva (e.g., animal or human bites)
– All wounds should be cleaned, dirt or foreign material removed, and
necrotic material removed or debrided
2. Antibiotics
– Metronidazole 500 mg IV or orally every 6 hours for 5-10 days in
adults
– Procaine penicillin G 1.2 million units/day intramuscularly in adults
– Aqueous crystalline penicillin G 4 million units IV daily in divided
doses every 6 hours for 5-10 days in adults
3. Evaluate immunization status of the patient
4. Assess need for administering Tetanus
Immunoglobulin (TIG) for prophylaxis
 S u m m a r y G u id e t o T e t a n u s P r o p h y la x is
in R o u t in e W o u n d M a n a g e m e n t
AS S ES S WOUND

All other wounds (contaminated with dirt, feces, saliva,

A clean, minor wound soil; puncture wounds; avulsions; wounds resulting from
flying or crushing objects, animal bites, burns, frostbite)

Has patient completed a primary Has patient completed a primary

tetanus diphtheria series?1,7 tetanus diphtheria series?1,7

No/Unknown Yes No/Unknown Yes

Adminis te r vac c ine today. 2,3,4 Was the most recent Adminis te r vac c ine and Was the most recent
Instruct patient to complete dose within the past te tanus immune g obulin dose within the past
series per age-appropriate 10 years? (TIG) no w.2,4,5,6,7 5 years?7
vaccine schedule.

No Yes No Yes

Adminis te r vac c ine to day. 2,4 Vac c ine no t ne e de d to day. Adminis te r vac c ine today. 2,4 Vac c ine no t ne e de d to day.
Patient should receive next Patient should receive next Patient should receive next Patient should receive next
dose per age-appropriate dose at 10-year interval after dose per age-appropriate dose at 10-year interval after
schedule. last dose. schedule. last dose.

4
1
A primary series consists of a minimum of 3 doses of tetanus- and diphtheria- Tda p* is preferred for persons 10 through 64 years of age if using Adacel1 or 10
containing vaccine (DTaP/DTP/Tdap/DT/Td). years of age and older if using Boostrix1 who have never received Tdap.
2
Age-appropriate vaccine: Td is preferred to tetanus toxoid (TT) for persons 7 through 9 years of age, or ≥65
DTaP for infants and children 6 weeks up to 7 years of age (or DT pediatric if years of age if only Adacel1 is available, or those who have received a Tdap
pertussis vaccine is contraindicated); previously. If TT is administered, an adsorbed TT product is preferred to fluid TT.
Tetanus-diphtheria (Td) toxoid for persons 7 through 9 years of age; and ≥65 (All DTaP/DTP/Tdap/DT/Td products contain adsorbed tetanus toxoid.)
5
years of age; Give TIG 250 U IM for all ages. It can and should be given simultaneously with the
Tdap for persons 10 through 64 years of age if using Adacel1 or 10 years of age tetanus-containing vaccine.
6
and older if using Boostrix1, unless the person has received a prior dose of Tdap.* For infants <6 weeks of age, TIG (without vaccine) is recommended for “dirty”
3
No vaccine or TIG is recommended for infants <6 weeks of age with clean, minor wounds (wounds other than clean, minor).
7
wounds. (And no vaccine is licensed for infants <6 weeks of age.) Persons who are HIV positive should receive TIG regardless of tetanus
immunization history.
*Tdap vaccines: Immunization Program
Adacel (Sanofi) is licensed for persons 11 through 64 years of age. P.O. Box 64975
Boostrix (GSK) is licensed for persons 10 years of age and older. St. Paul, MN 55164-0975
1
Brand names are used for the purpose of clarifying product characteristics and are not in 651-201-5414, 1-877-676-5414
www.health.state.mn.us/immunize (9/12) IC# 141-0332
any way an endorsement of either product.
Supportive Care
■ Neutralization of unbound toxin – TIG
■ Airway management
– Admission to ICU for close monitoring and airway management
■ Control of muscle spasms
– Benzodiazepine:
■ Diazepam initially an IV dose of 0.1 - 0.3 mg/kg body weight, repeated
at intervals of 1 - 4 hours. Continuous IV infusion of 3 – 10 mg/kg body
weight per 24 hours can also be used
– MgSO4:
■ 5 gm (or 75mg/kg) intravenous loading dose, then 2–3 grams per
hour until spasm control is achieved
■ Monitor patellar reflex
– Intrathecal baclofen
■ Management of dysautonomia
TETANUS VACCINATION
Tetanus Toxoid
■ First produced in 1924
■ Consists of formaldehyde-treated C. tetani
■ Indication: For booster injection (>7 years and
older), NOT indicated for primary immunization
■ Available in:
– Single preparation
– Combined as DT, Td, DTaP, Tdap
■ Inject intramuscularly or subcutaneously in vastus
lateral or deltoid
■ Antitoxin levels decrease with time. As a result,
routine boosters are recommended every 10 years
Tetanus Immunoglobulin
■ Consists of IgG to tetanus toxin
■ Indication: Post-exposure prophylaxis for tetanus
prone injuries
■ Dosage: 250IU
■ Inject intramuscularly or subcutaneously
■ Antitoxin levels decrease with time. As a result,
routine boosters are recommended every 10 years
THANK YOU
REFERENCES
1. WHO. Current recommendations for treatment of
tetanus during humanitarian emergencies. 2010.
Downloaded from: https://
www.who.int/diseasecontrol_emergencies/who_h
se_gar_dce_2010_en.pdf

2. Rodrigo C, Fernando D, Rajapakse S.

Pharmacological management of tetanus: an
evidence-based review. Crit Care. 2014; 18(2): 217.