Objectives: To determine various prognostic factors in tetanus patients during the period 2016 - 2017. Subjects: 64 patients were diagnosed tetanus, ages over 17, treated in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases from June, 2016 to April, 2017.
Trang 1A CLINICAL RETROSPECTIVE STUDY OF PROGNOSTIC FACTORS IN TETANUS PATIENTS (2016 - 2017)
Hoang Vu Hung*; Nguyen Lan Phuong*; Dinh Thi Phuong Lien* Han Minh Thuy**; Hoang Thi Thanh**; Luu Thi Nhan**
SUMMARY
Objectives: To determine various prognostic factors in tetanus patients during the period
2016 - 2017 Subjects: 64 patients were diagnosed tetanus, ages over 17, treated in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases from June, 2016 to April, 2017 Method: The cross-sectional retrospective, descriptive study Results: A total of the 64 patients with diagnosis of tetanus, had 53 male (70.31%) and 15 female (29.69%) The mean age was 58.7 ± 15.7 years (range 18 - 94) The outcomes of treatment were divided into two groups: 7 patients with dead, severe disease and 57 survivors There was a significant difference between two groups in patients with dead and more severe disease and cured patients observed in relation to more severe prognostic factors were the incubation period < 14 days and period of onset within 24 hours, site of infection, the number of convulsion over 10 seizures, frequency of pulse with p< 0.05 Conclusions: In this study, we determined severe prognostic factors of tetanus disease included the time of onset within 24 hours; level of lockjaw lesser 1 cm; over 10 convulsions within 24 hours; increase of sputum and sweat; frequency of pulse over 110 cycles per minute
* Keywords: Tetanus; Prognostic factors; 2016 - 2017
INTRODUCTION
Tetanus is a severe infectious disease
caused by the exotoxin produced by
Clostridium tetani The widespread use of
tetanus vaccine in prophylaxis programs
has led significantly decline in incidence,
but tetanus disease remains to be an
important public health problem associated
with high mortality all over the world,
especially in developing countries [6, 8]
Therefore, it is very crucial to identify
valuable prognostic factors of tetanus to
reduce the mortality rate In 1975,
Darka-Senegal, International Conference on tetanus
disease gave a consensus including six important prognostic factors: the period of incubation and the time of onset, the presence of muscle spasms, the port of entry, the level of fever, the frequency of pulse [7]
However, diagnosis of tetanus is main clinical, whereas treatment is the best done, prognostic factors are showed above does still not reflect all the follow-up process of diseases So, it is very necessary to determine more sufficient factors for predicting tetanus disease Vietnam is a developing country with tropical climate, located in region of countries with high
* 103 Military Hospital
** Vietnam Military Medical University
Corresponding author: Hoang Vu Hung (dr.hoangvuhung@yahoo.com)
Date received: 10/06/2017
Date accepted: 07/08/2017
Trang 2prevalence of tetanus Even though there
were the Expanded Immunization Program
and the advance of the treatment methods
that helpe to minimize significantly the
mortality rate of patients with diagnosis of
tetanus, the treatment and prognosis of
tetanus are still a great issue to be
elucidated Because of the prolonged
hospital stay, the high cost of treatment,
and confronted complications or even death,
tetanus remains major health problem and
challenging
There were many tetanus patients
admitted in the Department of Infectious
Diseases at 103 Hospital and National
Hospital of Tropical Diseases From 2004 -
2009, Department of Infectious Diseases
at 103 Hospital treated 36 patients with
diagnosis of tetanus, the morality rate was
observed 27.8% [5] In recent years, both
two hospitals continues enrolled a lot of
tetanus cases; but it is still lack of the
comprehensive research reported to access
about the clinical features, severe prognostic
factors of diseases Therefore, this study
is to: Point out severe prognostic factors of
patients with tetanus during 2016 - 2017
SUBJECTS AND METHODS
A total of the 64 patients aged > 17 years
with diagnosis of tetanus, who admitted to
the Department of Infectious Diseases of
103 Hospital and National Hospital of
Tropical Diseases between June, 2016
and April, 2017 enrolled in this
cross-sectional descriptive study The study
protocol was reviewed and approved by
the institutional review board of 103 Hospital
and National Hospital of Tropical Diseases
Patients were divided into two groups according to the outcomes of treatment:
57 survivors and 7 non-survivors:
* Inclusion criteria [1]:
- Patients had suspicious wound with the point of entry
- Clinical symptoms at onset of the first trismus, then skeletal muscles spasm
of the head, neck, and trunk
- Patients had percusive seizure with increased muscular tone
Clinical data were recorded and data sheet was used to collect the following data: age, gender, address, occupation, risk factor, type and duration of presenting first symptoms, duration of hospital stay, physical signs, laboratory parameters, complication(s), mode of treatment, outcomes at hospital discharge and causes of death, time period of incubation (time from injury to the appearance of the first symptoms) and period of onset (interval between the first symptoms and the first spasm), the number of eclampsia and pulse frequency were determined
Data were analyzed and compared between patients in group 1 and group 2 using SPSS 13.0 Chi-square test used for categorical variables or Fisher’s exact tests as appropriate and student’s t-tests and Mann - Whitney U test for quantitative variables Logistic regression was used to determine prognostic factors affecting deaths from tetanus disease To find some significant prognostic factors of tetanus, p values
< 0.05 were considered as statistical significance
Trang 3RESULTS AND DISCUSSION
1 General characteristics of patients
Among 64 patients with tetanus, there were 45 male (70.31%) and 19 female (29.69%) The mean age was 58.7 ± 15.7 years (range 18 - 94), patients with the highest age was 94 years, whereas, the lowest age was 21 years Our data were comparable with studies reported by Truong Thi Dieu Minh (male/female ratio was 1.5/1) [2] and Nguyen Thi Tam observed male patients had higher threefold ages than female patients
2 Severe prognostic factors in tetanus patients
Patients with age > 60 years had higher fatality rate as compared with those under age > 60 years (85.71% vs 33.33%) However, this difference was not statistically significant with p > 0.05 We did not observe any differences between the two groups in relation to age group above These results were different from that of Hoang Tien Tuyen et al suggested that tetanus patients had closed wounds, ligaments, bruised, combined infection as a major prognostic factor in the outcome of tetanus treatment [5] This difference could be explained that it was associated with size of samples, patient characteristics and the time point at the beginning of the study The study observed most patients had the port of entry in soft tissue wound There was a statistically significant relationship with respect to the entry sites and outcomes of treatment
Table 1: Association between age group and port of entry with treatment outcome
Dead, severe disease Survivors
Treatment
p
Aged group
≥ 60
> 0.05
Entry sites
Soft tissue wound
Non-soft tissue wound
> 0.05
The most common site of infection was lower limbs (37 of 64 patients), and head, body, upper limbs (22 of 64 patients), while 5 patients were not identified site of injury Most patients with infection in lower limbs, head, body, upper limbs had higher cured rate compared deceased or severed patients However, there was a significant difference between two groups associated with infection sites observed In this study,
52 of 64 patients had received SAT injection after injury and among 12 patients had not been used SAT injection after trauma, 7 patients died and more severe form of tetanus
We had showed that a significant difference between died and survived patient groups
in relation to SAT use status after injury
Trang 4Table 2: Relationship between sites of infection and the SAT injection status after
injury with the outcome of treatment
Dead, severe disease Survivors Treatment results
p
Site of infection
Lower limbs
Head, body, upper limbs
Unknown
4
3
0
57.14 42.86
0
33
19
5
57.89 33.33 8.78
> 0.05
Injection SAT vaccination
Yes
No
0
7
100
0
52
5
91.23 8.77
< 0.05
100% of patients died and more severe disease had the period of incubation ≤ 14 days while patients cured had the period of incubation > 14 days There was a significant difference between the two groups observed Some authors found that patients with an incubation period of less than 14 days was prognostic factors of mortality [3, 7] In this study, 13 of 64 patients had a period of onset less 24 hours, whereas 51 patients with period of onset more than 24 hours prior to hospital admission The study results demonstrated a significant difference between two groups associated with the period of onset before and after 24 hours This result indicated a short period of onset less 24 hours was a predictor of disease
Table 3: Relationship between incubation time and onset time with the outcome of
treatment
Dead, severe disease Survivors Treatment results
p
Incubation period (days)
≤ 14
>14
Unknown
7
0
0
100
0
0
40
12
5
70.18 21.05 8.77
> 0.05
Onset period (hours)
≤ 24
> 24
4
3
57.14 42.86
9
48
15.79 84.21
< 0.05
Table 4: Relationship between level of trismus and number of convulsion/24 hours
with treatment results
Dead, severe disease Survivors Treatment results
p
Level of trismus
≤ 1 cm
> 1 cm
5
2
71.43 28.57
19
38
33.33 66.67
< 0.05
Number of convulsion
≤ 10
10 - 100
> 100
0
6
1
0 85.71 14.29
48
9
0
84.21 15.79
0
< 0.05
Trang 5In this study, we observed a significant
association between two groups of patients
died had a maximal trismus ≤ 1 cm, with
those cured (p < 0.05) In addition, there
was a statistically significant between the
two groups in relation to the number of
convulsion observed As compared with
studies reported by Nguyen Thi Tam,
Nguyen Van Nhung indicated that tetanus
patients with maximum less than 1 cm
had the highest mortality, the patients with
trismus more than 2 cm had no mortality
[3, 4] Thus, at the onset period, monitoring
and access the level of trismus had shown
to be a prognostic significance Patients with stronger lockjaw had the higher the mortality or more severe disease
100% of patients died, and more severe illness, had the number of seizures within
24 hours were more than 10 seizures, whereas cured group was lesser than 10 seizures within 24 hours The difference between the two groups was statistically significant with p < 0.05, indicated that the number of seizures within 24 hours was a severe prognostic factor of tetanus disease
Table 5: Relationship between increased sputum, sweating with the outcome of treatment
Dead, severe disease Survivors Treatment results
Increase sputum,
p
100% of patients died and more severe disease had autonomic disregulation leading
to increased sputum and perspiration, while cured group was 66.67% The difference between the two groups was statistically significant (p < 0.05) This data are also comparable with the results of Truong Thi Dieu Minh's study, patients with mortality rate had increased sputum and sweat were significantly higher than the control group (91.2% vs 22.4%, p < 0.05) [2]
Table 6: Relationship between temperature and pulse frequencies at full-blast time
with the outcome of treatment
Dead, severe disease Survivors Treatment results
p
Temperature
1
1
3
2
14.28 14.28 42.86 28.58
9
17
25
6
15.79 29.82 43.86 10.53
> 0.05
Frequency pulses
> 110 cycles/min
≤ 110 cycles/min
5
2
71.43 28.57
18
39
31.58 68.42
< 0.05
Trang 628.58% of patients died, severe illness
had high fever with temperature > 39oC,
higher than the group cured (10.53%)
However, the difference between the two
groups was not statistically significant with
p > 0.05 Truong Thi Dieu Minh's study so
found that patients with body temperature
> 390C had a higher mortality rate, but not
statistically significant when compared with
the group control (60% vs 39.6%) [2]
71.43% of patients with fatal, severe
disease, rapid pulse frequency > 110 cycles
per minute, while cured patients were
31.58% The difference between two groups
was a statistically significance with p < 0.05
Thus, the pulse frequency > 110 cycles/minute
was a significant severe predictor for
tetanus diseases
CONCLUSION
In conclusion, we studied 64 tetanus
patients treated in the Department of
Infectious Diseases of 103 Hospital and
National Hospital of Tropical Diseases
from June 2016 to April, 2017 to determine
prognostic factors of tetanus disease
This study result indicated that severe
predictors of tetanus patients concluded:
- The onset period was shorter than
24 hours
- Trismus (the level of lockjaw) less than
1 cm
- Presence of over 10 convulsions within
24 hours
- Increase of sputum and sweat
- Frequency of pulse over 110 cycles
per minute
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