Tetanus

Last updated: August 2022

 

Tetanus is a severe infection due to the bacillus Clostridium tetani, found in soil, and human and animal waste. The infection is noncontagious.

Clostridium tetani is introduced into the body through a wound and produces a toxin whose action on the central nervous system is responsible for the symptoms of tetanus.

Tetanus is entirely preventable by vaccination. It occurs in people who have not been fully vaccinated before exposure or have not received adequate post-exposure prophylaxis. In these individuals, most breaks in the skin or mucous membranes carry a risk of tetanus, but the wounds with the greatest risk are: the stump of the umbilical cord in neonates, puncture wounds, wounds with tissue loss or contamination with foreign material or soil, avulsion and crush injuries, sites of non-sterile injections, chronic wounds (e.g. lower extremity ulcers), burns and bites. Surgical or obstetrical procedures performed under non-sterile conditions also carry a risk of tetanus.

Clinical features

Generalised tetanus is the most frequent and severe form of the infection. It presents as muscular rigidity, which progresses rapidly to involve the entire body, and muscle spasms, which are very painful. Level of consciousness is not altered.

Children and adults

• Average time from exposure to onset of symptoms is 7 days (3 to 21 days).
• Muscular rigidity begins in the jaw muscles (difficulty with then inability to open mouth [trismus] preventing the patient from speaking, eating), spreading to the face (fixed smile), neck (difficulty with swallowing), to the trunk (restriction of respiratory muscles; hyperextension of spine [opisthotonus]), to the abdomen (guarding) and to the limbs (flexion of the upper limbs and extension of the lower limbs).
• Muscle spasms, which are very painful, appear at the onset or when muscular rigidity becomes generalised. They are triggered by stimuli (noise, light, touch) or arise spontaneously. Spasms of the thoracic and laryngeal muscles may cause respiratory distress or aspiration.

Neonates

• In 90% of cases, initial symptoms appear within 3 to 14 days of birth.
• The first signs are significant irritability and difficulty sucking (rigidity of the lips, trismus) then rigidity becomes generalised, as in adults. Any neonate, who initially sucked and cried normally, presenting with irritability and difficulty sucking 3 to 28 days after birth and demonstrating rigidity and muscle spasms should be assumed to have neonatal tetanus.

Treatment

Hospitalisation is needed and usually lasts 3 to 4 weeks. Correct management can reduce mortality even in hospitals with limited resources.

General measures

• Ensure intensive nursing care.
• The patient should be in a dark, quiet room. Blindfold neonates with a cloth bandage.
• Handle the patient carefully, while sedated and as little as possible; change position every 3 to 4 hours to avoid bedsores.
• Teach family the danger signs and instruct them to call the nurse for the slightest respiratory symptom (cough, difficulty breathing, apnoea, excessive secretions, cyanosis, etc.).
• Establish IV access for hydration, IV injections.
• Gentle suction of secretions (mouth, oropharynx).
• Insert a nasogastric tube for hydration, feeding and administration of oral medications.
• Provide hydration and nutrition in feeds divided over 24 hours. In neonates, give expressed breast milk every 3 hours (risk of hypoglycaemia).

Neutralisation of toxin

human tetanus immunoglobulin IM
Neonates, children and adults: 500 IU single dose, injected into 2 separate sites

Inhibition of toxin production

metronidazole  ^{a Citation a. Clindamycin IV for 7 days is an alternative (for doses, see Periorbital and orbital cellulitis, Chapter 5).} IV infusion (30 minutes; 60 minutes in neonates) for 7 days

• Neonates:
  • 0 to 7 days: 15 mg/kg on D1 then, after 24 hours, 7.5 mg/kg every 12 hours
  • 8 days to < 1 month (< 2 kg): same doses
  • 8 days to < 1 month (≥ 2 kg): 15 mg/kg every 12 hours
• Children 1 month and over: 10 mg/kg every 8 hours (max. 1500 mg daily)
• Adults: 500 mg every 8 hours

Control of rigidity and spasms, and sedation of the patient

Diazepam should decrease the frequency and intensity of spams without causing respiratory depression. The dose and frequency of administration depend on the patient’s clinical response and tolerance.

 

 

Neonates

diazepam emulsion for injection (10 mg ampoule, 5 mg/ml, 2 ml) 0.1 to 0.3 mg/kg by slow IV injection (3 to 5 minutes) every 1 to 4 hours depending on the severity and the persistence of the spasms as long as the RR is ≥ 30. If despite hourly diazepam the spasms persist, start a continuous infusion of diazepam with an electric syringe: 0.1 to 0.5 mg/kg/hour (2.4 to 12 mg/kg every 24 hours). Start with 0.1 mg/kg/hour and if symptoms persist, increase by 0.1 mg/kg/hour as long as RR is ≥ 30. If in spite of 0.5 mg/kg/hour symptoms persist, the dose can be increased up to 0.8 mg/kg/hour as long as the RR ≥ 30. Diluted diazepam emulsion does not keep for more than 6 hours.   Example: Neonate weighing 3 kg (administration by electric syringe) 0.1 mg/kg/hour x 3 kg = 0.3 mg/hour Dilute one 10 mg ampoule of diazepam emulsion for injection in 50 ml of 10% glucose to obtain a solution containing 0.2 mg of diazepam per ml. Administer 1.5 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour i.e. 0.3 (mg/hour) ÷ 0.2 (mg/ml) = 1.5 ml/hour].   If an electric syringe is not available, diluting the diazepam emulsion in an infusion bag for continuous infusion may be considered. Weigh the risks associated with this mode of administration (accidental bolus or insufficient dose). The infusion should be monitored closely to avoid any change, however small, of the prescribed rate.

Children > 1 month and adults

Same doses and protocol as in neonates but: Use diazepam solution for injection 5 mg/ml: (10 mg ampoule, 5 mg/ml, 2 ml). (a) Citation a. Administer the first dose rectally if an IV cannot be placed immediately. These doses can be administered as long as the RR is: ≥ 30 in children under 1 year ≥ 25 in children 1 to 4 years ≥ 20 in children 5 to 12 years ≥ 14 in children over 12 years ≥ 12 in adults   Examples: Child weighing 6 kg (continuous IV infusion using a pediatric infusion set; 1 ml = 60 drops) 0.1 mg/kg/hour x 6 kg = 0.6 mg/hour Dilute one 10 mg ampoule of diazepam solution for injection in 50 ml of 5% glucose (10% glucose if child < 3 months) to obtain a solution containing 0.2 mg of diazepam per ml. Administer 3 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour i.e. 0.6 (mg/hour) ÷ 0.2 (mg/ml) = 3 ml/hour] or 3 drops/minute (in a paediatric infusion set ml/hour = drops/minute). Adult weighing 60 kg (standard adult infusion set, 1 ml = 20 drops) 0.1 mg/kg/hour x 60 kg = 6 mg/hour Dilute 5 ampoules of 10 mg of diazepam solution (50 mg) in 250 ml of 0.9% sodium chloride or 5% glucose to obtain a solution containing 0.2 mg of diazepam per ml. Administer 30 ml/hour [dose (in mg/hour) ÷ dilution (in mg/ml) = dose in ml/hour e.g. 6 (mg/hour) ÷ 0.5 (mg/ml) = 30 ml/hour] or 10 drops/minute.

Count the volume of the infusion of diazepam as part of the patient’s daily fluid intake.

 

When the frequency and severity of the spasms have decreased, start weaning the diazepam (gradually decrease the rate of infusion):

• Calculate the total daily dose of IV diazepam and administer it orally in 4 divided doses, 6 hours apart, via nasogastric (NG) b Citation b. Administration of oral diazepam tablets to infants: calculate the exact dose of diazepam, e.g. to obtain 0.5 mg of diazepam, cut a scored diazepam 2 mg tablet in half along scoring then split in half again. Crush quarter tablet and dissolve in expressed breast milk or infant formula.  tube.
• Give first NG dose and decrease rate of IV infusion by 50%.
• Give second NG dose and stop IV diazepam infusion.
• If withdrawal signs c Citation c. Withdrawal signs: excessive irritability, tremors, increased muscle tone, frequent yawning, poor feeding, watery stools and sweating. appear, wean more slowly.
• Once on diazepam PO, wean by 10 to 20% of the original dose daily, until at a dose of 0.05 mg/kg every 6 hours.
• Then increase the interval from every 6 hours to every 8 hours for 24 hours as tolerated (wean more slowly if withdrawal signs appear).
• Continue to increase the interval between the doses from every 8 hours to every 12 hours and then to every 24 hours before stopping the diazepam.
• Each step should be for 24 hours or more if withdrawal signs appear.

 

Notes:

• It is often at these smaller doses that it is difficult to wean diazepam. If this is the case, slow the wean further: dropping the % wean (e.g. 5% wean every 24 hours instead of 10% wean) or increasing the interval between weans (e.g. going from every 24 hours to every 48 hours).
• If the patient is also receiving morphine, wean diazepam first then, wean morphine.
• Non-pharmacological measures to reduce withdrawal: reduce environmental stimuli; swaddle infants, frequent feedings.
• Infants who have had tetanus remain hypertonic, even when they are no longer having spams.

Treatment of pain

morphine PO (via nasogastric tube) if necessary (see Pain, Chapter 1).
When morphine is administered with diazepam the risk of respiratory depression is increased, thus closer monitoring is required. When morphine is no longer required, wean the same way as diazepam.

Treatment of the entry point and associated infections

• Search systematically the entry wound. Provide local treatment under sedation: cleansing and for deep wounds, irrigation and debridement.
• Cord infection: do not excise or debride; treat bacterial omphalitis and sepsis, add to metronidazole IV: cloxacillin IV + cefotaxime IV or cloxacillin IV + gentamicin IV (for doses, see Bacterial meningitis).

Tetanus vaccination

As tetanus does not confer immunity, vaccination against tetanus must be administered once the patient has recovered.
In case of neonatal tetanus, initiate the vaccination of the mother.

Prevention

Of critical importance, given the difficulty of treating tetanus once established.

1) Post-exposure prophylaxis

• In all cases:
  • Cleansing and disinfection of the wound, and removal of any foreign body.
  • Antibiotics are not prescribed routinely for prophylaxis. The decision to administer an antibiotic (metronidazole or penicillin) is made on a case-by-case basis, according to the patient’s clinical status.
• Depending on pre-exposure vaccination status:
  Tetanus vaccine (TV) d Citation d. Tetanus-containing vaccine, such as Td or DTP or DTP + HepB or DTP + HepB + Hib according to availability and patient’s age.  and immunoglobulin: see indications below.

 

 

tetanus vaccine IM
Children and adults: 0.5 ml per dose
If no vaccination or unknown vaccination status: administer at least 2 doses at an interval of 4 weeks.
If incomplete vaccination: administer one dose.
Then, to ensure long-lasting protection, administer additional doses to complete a total of 5 doses, as indicated in the table below.

 

human anti-tetanus immunoglobulin IM
Children and adults: 250 IU single dose; 500 IU for wounds more than 24 hours old.
Inject the vaccine and the immunoglobulin in 2 different sites, using a separate syringe for each.

2) Routine vaccination (pre-exposure prophylaxis)

• Children: 6 doses in total: a first series of 3 doses of DTP or DTP + HepB or DTP + HepB + Hib before the age of 1 year, administered at an interval of 1 month (e.g. at the age of 6, 10 and 14 weeks), then a dose of a vaccine containing tetanus toxoid between the age of 12 and 23 months, a dose between the age of 4 to 7 years, then a dose between the age of 12 and 15 years.
• Women of childbearing age: 5 doses during the reproductive years: a series of 3 doses of Td with an interval of at least one month between the first and second dose and an interval of at least 6 months between the second and third dose, then two other doses, each at minimum interval of one year, e.g. during pregnancies (see table below).
• Pregnant women: if a woman has never been vaccinated or if her vaccination status is unknown: 2 doses of Td during the pregnancy to reduce the risk of tetanus in mother and  neonate: the first as soon as possible during the pregnancy and the second at least 4 weeks later and at least 2 weeks before delivery. This vaccination schedule protects more than 80% of neonates from tetanus. A single dose offers no protection