Tetanus 1

Presented by
TETANUS
Dr. Syeda Maryam Asad (1-12)
Dr. Saba Rashid (13-19)
Dr. Mustafa Kamal (20-30)
OBJECTIVES
Introduction of the topic

Infectious agent
Pathogenesis
Transmission
Epidemiology
Clinical presentation
Management
Prevention
Deterrence and Patient education
INTRODUCTION
 TETNOS - Greek word – which means to

stretch.
 Tetanus is acute bacterial disease caused by

neurotoxin tetanospasmin elaborated by
clostridium tetani, and characterized by
prolonged contraction of skeletal muscle
fibers.
INFECTIOUS AGENT
 The causative agent of tetanus

is Clostridium tetani, a spore-forming,
anaerobic, gram-positive bacterium.
Ubiquitous in the environment,
spores of C. tetani germinate into
toxin-producing bacteria when they
enter the body under specific
conditions.
PATHOGENESIS
 The clostridial neurotoxins responsible for tetanus are proteins consisting of

three domains endowed with different functions: neurospecific binding,
membrane translocation and proteolysis for specific components of the
neuroexocytosis apparatus.
 Tetanus neurotoxin (TeNT) binds to the presynaptic membrane of the
neuromuscular junction, is internalized and transported retroaxonally to the
spinal cord.
 The spastic paralysis induced by the toxin is due to the blockade of
neurotransmitter release from spinal inhibitory interneurons by binding to the
GABA receptors.
TRANSMISSION
 Direct contamination of open wounds and non-intact skin
including wounds contaminated with dirt, animal or human
excreta or saliva, or necrotic tissue.
 Even wounds without visible contamination can become
infected with tetanus spores.
 Tetanus transmission has been associated with abortion,
dental infection, injection drug use, otitis media,
pregnancy, and surgery.
 Neonatal tetanus is typically acquired when spores
contaminate the umbilical cord due to unhygienic delivery
practices. Direct person-to-person transmission does not
occur.
 It is the only vaccine preventable disease that is infectious
but not contagious.
EPIDEMIOLOGY
 Tetanus is distributed worldwide and can affect any age group. It is more
common in rural and agricultural regions; areas where contact with soil or
animal excreta is likely; warm and moist environments; and areas where
immunization against tetanus is inadequate. Because the spores exist in the
environment, tetanus cannot be eradicated. In 2020, over 11,750 tetanus
cases across the globe were reported to the World Health Organization /
United Nations Children’s Fund, of which 2,230 occurred in neonates. Most
tetanus cases were reported from countries in Africa and Southeast Asia.
 Maternal and neonatal tetanus elimination, defined as <1 neonatal tetanus
case per 1,000 live births per year in every district in a country, has not
been achieved in Pakistan.
 Any traveler not up to date with tetanus vaccination is at risk of acquiring
tetanus infection.
TYPES OF TETANUS
 Based on the clinical features, there are four main types of tetanus.
1. Generalized tetanus
2. Neonatal tetanus
3. Localized tetanus
4. Cerebral tetanus
CLINICAL FEATURES
 Generalized Tetanus
 Most common form of the disease,80%
 The incubation period is 7 days, 15% cases
occur within 3 days and 10% after 14 days.
 Characterized by increase muscle tone and
generalized muscle spasms.
 Typically, patient first notices increased tone in
masseter muscle (lock jaw i.e. trismus).
 Dysphagia
 Stiffness and painful neck, shoulder and back
muscles.
 Rigid abdomen
 Hands and feet are relatively spared.
 Sustained contraction of facial muscle result in grimace risus sardonicus.
 Contraction of back muscle produces an arched back opisthotonus
 Some patient develop paroxysmal, painful generalized muscle spasm that
results in cyanosis and threaten ventilation.
 These spasm occur repetitively and may be spontaneous or provoked by even
slightest stimulation. A constant threat during generalized spasm is reduced
ventilation, apnea or laryngospasm.
MANAGEMENT
 Diagnosis depends on clinical findings.

 The treatment of tetanus is based on the severity of the disease. However, all patients must
have the following goals of treatment:
1. Early wound debridement
2. Supportive management
3. Antibiotic therapy
4. Early intramuscular or intravenous administration of the human tetanus immunoglobulin
(HTIG)
5. Neuromuscular blockade
6. Controlling various manifestations
7. Managing complications
TETNUS IMMUNOGLOBULIN
 First-line treatment includes HTIG, which removes

released tetanospasmin toxin; however, it does not
affect the toxin that is already bound to the central
nervous system.
 A dose of 500 U, either intramuscular or intravenous,
is as effective as larger doses.
 HTIG is injected intrathecally, especially in cases of
cerebral tetanus.
 In the case of generalized tetanus, therapeutic doses
(3000-6000 U) are also recommended.
MEDICATIONS

Although toxins are the main cause of disease, metronidazole has been shown
to slow the progression of the disease. Metronidazole has been shown to decrease
mortality, as well.
 Penicillin, which was used in the past for treatment, is no longer recommended after
discovering that it may have synergistic effects with tetanospasmin.
 Benzodiazepines are considered a cornerstone therapy for tetanus
manifestations.
 Diazepam is the most frequently studied and utilized drug in this regard. It reduces
anxiety but also causes sedation and relaxes muscles, thereby preventing lethal
respiratory complications. They are given in the form of continuous infusions to
prevent cardiovascular and respiratory complications.
 To prevent spasms that last more than 5-10 seconds, diazepam should be administered
IV, 10-40 mg every 1-8 hours. The dose of midazolam is 5-15 mg/hour IV.
 For patients with autonomic instability
 (labile blood pressure, hyperpyrexia, hypothermia).
 Magnesium is often used in combination with benzodiazepines to
manage these complications.
 It should be given IV in the form of a bolus of 5 g followed by a continuous
infusion at a rate of 2-3 g/hour until the spasm control has been achieved.
 During magnesium infusion, the patellar reflex needs to be monitored; if
areflexia develops, the dose should be reduced.
SUPPORTIVE
CARE
 Patient should be admitted in a
quiet dark room.
 In case of severe tetanus
patients are likely hospitalized
in the intensive care unit (ICU)
with sedation and mechanical
ventilation, which can affect
mortality and long-term
sequelae.
 Providing high-calorie diets to
compensate for increased
metabolic use from muscle
contractions is also important.
PROGNOSIS
The prognosis after

tetanus depends on the
time from the first
symptom to the first
spasm. In general, with a
short time to symptom
manifestation, the
prognosis is poor. The
recovery after tetanus is
slow and it can take
months.
Both neonatal and
cephalic tetanus have a
poor prognosis.
An established scale can be used to predict the prognosis of tetanus. One point is
given for each of the following:
 Incubation - shorter than 7 days
 Onset - less than 48 hours
 Causes of tetanus - burns, surgical wounds, septic abortion, umbilical stump,
open fractures, or intramuscular injection
 Addiction to opiates
 Generalized tetanus
 temperature - more than 104 F (40 C)
 Tachycardia - more than 120/min (150/min in neonates)
 The total score indicates disease severity:
 0-1 - mortality of less than 10%
 2-3 - mortality of 10-20%
 4 - mortality of 20-40%
 5-6 - mortality of more than 50%
PREVENTION
 Tetanus disease does not result in

immunity. Vaccination is the only
prevention against tetanus.
 Because immunity after vaccination wanes
over time, lifelong vaccination with
tetanus toxoid–containing vaccine (TTCV) is
necessary to attain and sustain immunity
against tetanus. All travelers should be up
to date with vaccination before departure.
 Children
 DTaP (diphtheria-tetanus-acellular pertussis) and DT

(diphtheria-tetanus) are indicated for children <7
years.
 while Tdap (tetanus-diphtheria-acellular pertussis)
and Td (tetanus-diphtheria) are indicated for children
≥10 years.
 Infants and children should receive 5 doses of DTaP at
2, 4, 6, and 15–18 months, and at 4–6 years;
adolescents should receive 1 dose of Tdap at 11–12
years of age. Children ≥7 years old can receive Tdap
for catch-up vaccination.
 Adults
 Adults should receive TTCV booster doses every 10
years. Adults who have never received Tdap should
receive Tdap; otherwise, clinicians can administer
either Td or Tdap.
 Previously unvaccinated pregnant people should
receive 2 doses of TTCV during their pregnancy.
PREVENTION OF NEONATAL
TETANUS
 Clean delivery practices
 3 cleans:
 clean hands, clean delivery surface, clean cord care
 Tetanus toxoid protects both mother and child.
 Unimmunized pregnant women: 2 doses tetanus toxoid
(16th-36th week)1st dose as early as possible during
pregnancy.2nd dose at least a month later or3 weeks before
delivery.
 Immunized pregnant women: a booster is sufficient.
 No need of booster in every consecutive pregnancy.
 To newborn of unimmunized mother, 500U HTIG within 6
hours of birth.
DETERRENCE AND
PATIENT EDUCATION
 The importance of childhood

immunizations and boosters
must be stressed.
 In developing and
underdeveloped countries
midwives and birth attendants
should be given training in
aseptic birth procedures.
 The basics of first aid and wound
care should be taught to all.
THANK YOU

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Presented by

Introduction of the topic

 TETNOS - Greek word – which means to

 Tetanus is acute bacterial disease caused by

 The causative agent of tetanus

 The clostridial neurotoxins responsible for tetanus are proteins consisting of

 Diagnosis depends on clinical findings.

 First-line treatment includes HTIG, which removes

The prognosis after

 Tetanus disease does not result in

 DTaP (diphtheria-tetanus-acellular pertussis) and DT

 The importance of childhood

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