<Disease review> Tetanus 감염 내과 / R3 이민혜

Introduction First described by Hippocrates Etiology discovered in 1884 by Carle and Rattone Passive immunization used for treatment and prophylaxis during World War I Tetanus toxoid first widely used during World War II

Clostridium tetani Anaerobic gram-positive rod, spore forming bacteria Spores found in soil, animal feces; may persist for months to years Multiple toxins produced with growth of bacteria Tetanospasmin estimated human lethal dose = 2.5ng/kg

Pathogenesis Anaerobic conditions allow germination of spores and production of toxins Toxin binds in central nervous system Interferes with neurotransmitter release to block inhibitor impulses Leads to unopposed muscle contraction and spasm

Epidemiology Reservoir : soil and intestine of animals and humans Transmission : contaminated wounds, tissue injury Temporal pattern : peak in summer or wet season Communicability : not contagious

Epidemiology

Secular trends in the US

Incidence of tetanus in Korea 질병관리본부 http://www.cdc.go.kr

Clinical features Incubation period; 8days (range, 3-21days) Three clinical forms Local (not common) Cephalic (rare) Generalized (most common) Generalized tetanus : descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms Spasms continue for 3-4 weeks; complete recovery may take months

Complications Laryngospasm Fractures Hypertension Nosocomial infections Pulmonary embolism Aspiration pneumonia Death

Diagnosis No laboratory findings characteristic of tetanus The diagnosis is entirely clinical and does not depend upon bacteriologic confirmation C. tetani Wound in only 30% of cases Can be isolated from patients who do not have tetanus

Medical management Antimicrobial therapy : relatively minor role in the management of tetanus, universally recommended Metronidazole(500mg IV every six to eight hours) : 7 to 10 days Alternative : penicillin G(2 to 4 million units IV every four to six hours) If tetanic spasms are occurring, supportive therapy and maintenance of an adequate airway are critical Tetanus immune globulin (TIG) : recommended for persons with tetanus Only help remove unbound tetanus toxin It cannot affect toxin bound to nerve endings A single intramuscular dose of 3,000 to 5,000 units Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available Active immunization with tetanus toxoid should begin or continue as soon as the person’s condition has stabilized

Tetanus toxoid Formalin-inactivated tetanus toxin Schedule 3 or 4 doses + booster Booster every 10 years Efficacy; approximately 100% Duration; approximately 10 years Should be administered with diphtheria toxoid as DTaP, DT, Td, or Tdap DTaP = Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed DT = Diphtheria, Tetanus toxoids - pediatric Td = Tetanus & diphtheria toxoids - adult Tdap = Tetanus & diphtheria toxoids and acellular pertussis vaccine

Td vs. Tdap JDT JADTP JDTPB Td vaccine Tdap vaccine Used for many years Protects against tetanus and diphtheria Tdap vaccine Licensed in 2005 First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria 11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose JDT JADTP JDTPB

Td vs. Tdap JDT JADTP JDTPB Td vaccine Tdap vaccine Used for many years Protects against tetanus and diphtheria Tdap vaccine Licensed in 2005 First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria 11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose JDT JADTP JDTPB

Wound management All wounds should be cleaned Necrotic tissue and foreign material should be removed Proper immunization plays the more important role

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