Treatment of Tetanus in the Elderly
The treatment of tetanus in elderly patients requires aggressive management including proper wound care, human tetanus immune globulin (TIG) administration (250 units IM), antimicrobial therapy, and intensive supportive care with particular attention to airway management and control of muscle spasms. 1
Initial Management
- Thorough wound cleaning and surgical debridement of necrotic tissue are critical first steps to remove C. tetani spores and eliminate anaerobic conditions favorable for bacterial growth 1
- Administer Human Tetanus Immune Globulin (TIG) 250 units intramuscularly to neutralize unbound tetanospasmin toxin 1, 2
- For tetanus-prone wounds in elderly patients with uncertain vaccination history, TIG should be prioritized, as older adults are at higher risk of tetanus infection and mortality 2
- Antimicrobial therapy should be initiated to eliminate C. tetani; metronidazole is the preferred agent 1
Management of Muscle Spasms and Autonomic Instability
- Diazepam is indicated for control of tetanus-related muscle spasms in the elderly 3
- For elderly patients with tetanus, diazepam dosing should start lower (2-5 mg) and be increased slowly due to age-related sensitivity 3
- Larger doses of diazepam may be required specifically for tetanus management compared to other indications 3
- Respiratory assistance should be readily available when administering diazepam for tetanus 3
- Mechanical ventilation is frequently required in elderly patients with severe tetanus, with a median weaning period of 31 days 4
Intensive Care Management
- Elderly patients with tetanus often require prolonged hospitalization (median 77 days) and extended mechanical ventilation 4
- Careful monitoring for autonomic instability is essential, as this is a common complication in tetanus 1
- Dysphagia may be an early and sometimes the only presenting symptom of tetanus in octogenarians, requiring heightened clinical suspicion 5
- The case-fatality ratio for tetanus remains high (8-18%) even with modern medical care, with higher rates among elderly patients 2, 1
Vaccination Following Recovery
- After recovery, complete the primary tetanus vaccination series in elderly patients with inadequate immunization history 1
- Tetanus disease does not confer immunity, so vaccination is essential to prevent recurrence 1
- Older adults have lower prevalence of protective antibody levels against tetanus (45% of men and only 21% of women aged >70 years) 2
- Elderly patients represent a disproportionate burden of tetanus cases, with 38% of reported cases occurring in those aged >65 years 2
Prevention Strategies
- Tetanus is entirely preventable through proper immunization 6
- Elderly patients should receive Td (tetanus and diphtheria toxoids) as the preferred preparation if they have not received a booster within the past 10 years 1
- For contaminated wounds, tetanus toxoid should be administered if the patient has not received a dose within the preceding 5 years 1
- Healthcare providers should assess tetanus vaccination status during routine encounters with elderly patients 7