Chapter 133. Tetanus (Part 3) pps

Tetanus Part 3 Vaccine Patients recovering from tetanus should be actively immunized see below because immunity is not induced by the small amount of toxin required to produce disease.

Chapter 133 Tetanus

(Part 3)

Vaccine

Patients recovering from tetanus should be actively immunized (see below) because immunity is not induced by the small amount of toxin required to produce disease

Additional Measures

Like all patients receiving ventilatory support, patients with tetanus require attention to hydration; nutrition; physiotherapy; prophylactic anticoagulation; bowel, bladder, and renal function; decubitus ulcer prevention; and treatment of intercurrent infection

Prevention

Active Immunization

All partially immunized and unimmunized adults should receive vaccine, as should those recovering from tetanus The primary series for adults consists of three doses: the first and second doses are given 4–8 weeks apart, and the third dose is given 6–12 months after the second A booster dose is required every 10 years and may be given at mid-decade ages—35, 45, and so on Combined tetanus and diphtheria toxoid, adsorbed (Td, for adult use)—rather than single-antigen tetanus toxoid—is preferred for persons >7 years of age Adsorbed vaccine is preferred because it produces more persistent antibody titers than fluid vaccine Two combined tetanus/diphtheria/attenuated pertussis vaccines have recently been approved: one (ADACEL) for adults 19–64 years of age and the other (BOOSTRIX) for adolescents 11–18 years of age The Advisory Committee on Immunization Practices has recommended a single dose of Tdap (ADACEL) for adults 19–64 years old who have not received Tdap

Wound Management

Proper wound management requires consideration of the need for (1) passive immunization with TIG and (2) active immunization with vaccine (Tdap

or Td; Table 133-1) The dose of TIG for passive immunization of persons with wounds of average severity (250 units IM) produces a protective serum antibody level for at least 4–6 weeks; the appropriate dose of TAT, an equine-derived

product, is 3000–6000 units Vaccine and antibody should be administered at separate sites with separate syringes

Table 133-1 Guide to Tetanus Prophylaxis and Routine Wound Management

Wound

Woundsa

Adsorbed Tetanus Toxoid

(Doses)

Tdap

or Tdb

TIG Tdap

or Tdb

TIG

a

Such as, but not limited to, wounds contaminated with dirt, feces, soil, and

saliva; puncture wounds; avulsions; and wounds from missile or crushing injuries, burns, and frostbite

b

Tdap is preferred to Td for adults 19–64 years old who have never received Tdap Td is preferred for adults who have received Tdap previously and

is used when Tdap is not available Td is also recommended for persons >64 years old If TT and TIG are both used, TT adsorbed rather than TT for booster use only (fluid vaccine) should be used

c

Yes, if ≥10 years have elapsed since the last TT-containing vaccine dose

d

Yes, if ≥5 years have elapsed since the last TT-containing vaccine dose

Note: Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular

pertussis vaccine, adsorbed; DT, diphtheria and tetanus vaccine; DTP, diphtheria, tetanus, and pertussis vaccine; Td, tetanus-diphtheria toxoid, adsorbed; TIG, tetanus immune globulin; TT, tetanus toxoid

Source: Modified from Centers for Disease Control and Prevention, 2006

Neonatal Tetanus

Preventive measures include maternal vaccination, even during pregnancy; efforts to increase the proportion of births that take place in the hospital; and the provision of training for nonmedical birth attendants

Prognosis

The application of methods to monitor and support oxygenation has markedly improved the prognosis in tetanus Mortality rates as low as 10% have been reported from units accustomed to handling such cases In the United States

in 2003, there were 20 cases and 2 deaths; no cases were in patients <18 years old, and 19 cases were ascribed to inadequate immunization The outcome is poor in neonates and the elderly and in patients with a short incubation period, a short interval from the onset of symptoms to admission, or a short period from the onset

of symptoms to the first spasm (period of onset) Outcome is also related to the extent of prior vaccination

The course of tetanus extends over 4–6 weeks, and patients may require prolonged ventilator support Increased tone and minor spasms can last for months, but recovery is usually complete

Further Readings

Abrutyn E, Berlin JA: Intrathecal therapy of tetanus: A meta-analysis JAMA 266:2262, 1991 [PMID: 1833565]

Ahmadsyah I, Salim A: Treatment of tetanus: An open study to compare the efficacy of procaine penicillin and metronidazole BMJ 291:648, 1985 [PMID:

3928066]

Bleck TP: Clostridium tetani (tetanus), in Principles and Practice of

Infectious Diseases, 5th ed, GL Mandell et al (eds) New York, Churchill

Livingstone, 2000, pp 2537–2543

Centers for Disease Control and Prevention: Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel MMWR 55(RR17):1, 2006

Centers for Disease Control and Prevention: Tetanus—Puerto Rico, 2002 MMWR 51:613, 2002

———: Tetanus surveillance—United States, 1998–2000 Surveillance

summaries, June 20, 2003 MMWR 52(SS-3):1, 2003

Cook TM et al: Tetanus: A review of the literature Br J Anaesth 87:477,

2001 [PMID: 11517134]

Hsu SS et al: Tetanus in the emergency department: A current review J Emerg Med 20:357, 2001 [PMID: 11348815]

McQuillan CM et al: Serologic immunity to diphtheria and tetanus in the United States Ann Intern Med 136:660, 2002 [PMID: 11992301]

Thwaites CL et al: Magnesium sulphate for the treatment of severe tetanus:

A randomized controlled trial Lancet 368:1436, 2006 [PMID: 17055945]

Bibliography

Bardenheier B et al: Tetanus surveillance—United States, 1995–1997 MMWR 47:1, 1998 [PMID: 9665156]

Bruggemann H et al: The genome sequence of Clostridium tetani, the

causative agent of tetanus disease Proc Natl Acad Sci USA 100:1316, 2003 [PMID: 12552129]

Farrar JJ et al: Tetanus J Neurol Neurosurg Psychiatry 69:292, 2000 [PMID: 10945801]

Lee DC, Lederman HM: Anti-tetanus toxoid antibodies in intravenous gamma globulin: An alternative to tetanus immune globulin J Infect Dis 166:642,

1992 [PMID: 1500750]

Sanford JP: Tetanus—forgotten but not gone N Engl J Med 332:812, 1995 [PMID: 7862186]

Turton K et al: Botulinum and tetanus neurotoxins: Structure, function and therapeutic utility Trends Biochem Sci 27:552, 2002 [PMID: 12417130]

Wesley AG, Pather M: Tetanus in children: An 11-year review Ann Trop Paediatr 7:32, 1987 [PMID: 2439001]

Yen JM et al: Role of quinine in the high mortality of intramuscular injection tetanus Lancet 344:786, 1994 [PMID: 7916074]