What is the management for tetanus (Tetanus infection)?

Management of Tetanus Infection

The management of tetanus requires prompt wound care, appropriate immunization, and supportive treatment including muscle relaxants, with tetanus immune globulin administration for those with tetanus-prone wounds and incomplete vaccination history. 1, 2

Initial Assessment and Wound Management

• Proper wound care and debridement are critical first steps in tetanus prevention 1, 2
• Thoroughly clean the wound to remove debris that might harbor Clostridium tetani spores 2
• Surgical debridement of necrotic tissue is necessary for wounds that might create anaerobic conditions favorable for C. tetani growth 2
• Primary wound closure is not recommended for tetanus-prone wounds with the exception of facial wounds, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics 1

Immunization Strategy

For Patients with Complete Primary Vaccination Series (≥3 doses):

• For clean, minor wounds: Administer tetanus toxoid booster if the patient has not received a dose within the past 10 years 1, 2
• For contaminated or tetanus-prone wounds: Administer tetanus toxoid if the patient has not received tetanus toxoid within the preceding 5 years 1

For Patients with Unknown or Incomplete Vaccination History:

• Consider patients with unknown or uncertain previous vaccination histories as having had no previous tetanus toxoid doses 1, 2
• Administer both tetanus toxoid-containing vaccine AND tetanus immune globulin (TIG) 1, 2

Vaccine Selection:

• For adults ≥7 years of age: Use Td (tetanus and diphtheria toxoids) as the preferred preparation 1
• Tdap (tetanus, diphtheria, and acellular pertussis) is preferred over Td if not previously given 1, 2
• For children <7 years of age: Use DTaP (diphtheria, tetanus, and acellular pertussis) 1, 2

Passive Immunization with Tetanus Immune Globulin (TIG)

• Human Tetanus Immune Globulin (TIG) is necessary for patients with tetanus-prone wounds who have not completed a primary vaccination series 1, 2
• The recommended prophylactic dose of TIG is 250 units intramuscularly for wounds of average severity 1, 2
• When tetanus toxoid and TIG are given concurrently, use separate syringes and separate injection sites 1, 2
• Prioritize TIG for persons aged >60 years and immigrants from regions other than North America or Europe if supplies are limited 1, 2

Treatment of Established Tetanus

• Administer Human Tetanus Immune Globulin (TIG) to neutralize unbound tetanus toxin 2, 3
• Provide antimicrobial therapy with metronidazole or penicillin to eliminate C. tetani and stop toxin production 3, 4
• Control muscle spasms with benzodiazepines, particularly diazepam 5, 3
  • For adults: 5-10 mg IV/IM initially, then 5-10 mg every 3-4 hours as needed 5
  • For severe tetanus, larger doses may be required 5
  • For infants over 30 days: 1-2 mg IV/IM every 3-4 hours as needed 5
  • For children 5 years or older: 5-10 mg every 3-4 hours as needed 5
• Ensure respiratory support is available, as respiratory failure is a common complication 5, 6
• Provide supportive care including IV fluids, nutrition, and management of autonomic instability 3, 4

Special Considerations

• Tetanus is more common in older adults (>60 years) who often lack protective antibody levels 2, 6
• The case fatality rate remains high (18-21%) even with modern medical care 1, 2
• Patients with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history 2, 7
• Tetanus can present with atypical symptoms, including abdominal rigidity, which may delay diagnosis 6, 4

Follow-up Care

• Ensure completion of the primary vaccination series for inadequately vaccinated patients 1, 2
• Educate patients about the importance of maintaining tetanus immunity with boosters every 10 years 1, 2

Common Pitfalls to Avoid

• Failing to obtain an accurate immunization history - patients with unknown vaccination histories should be treated as unvaccinated 1, 2
• Assuming that military service guarantees complete tetanus immunization 2, 7
• Delaying treatment while waiting for laboratory confirmation, as tetanus is a clinical diagnosis 6, 8
• Underestimating the need for intensive supportive care in established tetanus cases 3, 8