Management and outcome of adult generalized tetanus in a Chinese tertiary hospital.

Background: Tetanus is a rare surgical infectious disease with a high reported relevant mortality. It still remains a serious problem in public health, particularly in low-income and middle-income countries. The purpose of this study was to investigate the management and prognosis of adult generalized tetanus in our hospital. Methods: A total of 20 adult generalized tetanus patients were recruited in this retrospective observational study. Patients were retrieved from the hospital data base via discharge diagnosis. Patients were divided into two groups (Severe or Non-severe tetanus group) based on the severity of tetanus by using the Ablett classification. The differences between the two groups were compared. Results: The study included 11 males (55%) and 9 females (45%). All tetanus patients recovered. The median age was 53.5 years [IQR: 19-78]. There were 1 mild (Grade 1) case (5%),5 moderate (Grade 2) cases (25%), 2 severe (Grade 3) cases (10%), and 12 very severe (Grade 4) cases (60%). Nineteen patients (95%) did not have tetanus immunization before. The majority of patients were farmers (60%), and came from rural areas (60%). Thirteen (65%) patients had a history of puncture injury. The rate of wound debridement after admission was 60% overall. Thirteen (65%) patients required mechanical ventilation for a median of 21 [IQR:12-41] days. Autonomic instability occurred in 13 (65%) patients. Pulmonary infections occurred in 12 (60%) patients. Median duration of hospital stay was 29.5 [IQR:12-68] days. More patients in the Severe group needed ICU admission, wound debridement, mechanical ventilation and heavy sedation combined with muscle relaxants (p < 0.05). The hospital stay was significantly longer in patients in the Severe group (p < 0.05). Conclusion: After effective treatment, all adult patients with generalized tetanus in this study were cured and discharged. Severe tetanus requires early ICU treatment, wound debridement and effective treatment of autonomic instability.

Assessing the impact of the 2018 tetanus guidelines on knowledge and practices of emergency physicians in trauma patients: a national survey study.

Background: Tetanus remains a significant public health issue in China, with the approach of anti-tetanus prophylaxis in the emergency department resulting in both overuse, particularly of human tetanus immune globulin (TIG), and underuse with the tetanus vaccine. This is largely due to the absence of updated guidelines on tetanus prophylaxis before 2018. Our study aimed to evaluate the effects of the 2018 Chinese tetanus guidelines on the knowledge and practices of emergency physicians about tetanus prevention in trauma patients. Methods: From November 2019 to April 2020, we conducted a web-based survey involving 499 emergency physicians. The survey included a questionnaire covering knowledge, attitudes, and practices related to tetanus. We assessed the influence of the 2018 tetanus guidelines on the knowledge and practices of emergency physicians related to tetanus prevention for patients with trauma using multiple regression analysis. Results: The survey results showed that only 45.3% of the participants had received formal training on tetanus immunization, despite 53.3% reporting the availability of tetanus vaccines at their institutions. Physicians typically prescribed tetanus antitoxin or human TIG instead of tetanus toxoid (TT) to treat injuries, regardless of the patient's TT vaccination history. Among the respondents, those who were aware of the 2018 tetanus guidelines had higher mean scores on the general knowledge, risk knowledge, and treatment knowledge scales, with increases of 6%, 13%, and 9%, respectively, compared to those who were unaware of the guidelines. Awareness of the 2018 tetanus guidelines was associated with a high level of knowledge, as indicated by the general knowledge score, recommendation knowledge score, and total knowledge score, after adjusting for the effects of all variables on the knowledge, attitudes, and practices of the participants. A high level of education was also associated with a high level of knowledge indicated by the recommendation knowledge score and total knowledge score. Conclusions: Our study highlights a substantial gap in the attitudes, knowledge, and practices of emergency physicians in China regarding tetanus immunization. The results suggest an urgent need to promote the Chinese Expert Consensus Guidelines on tetanus to improve emergency physicians' knowledge and competence in tetanus prophylaxis. The findings underscore the importance of enhancing physicians' awareness of the latest guidelines to ensure appropriate and effective treatment for patients with tetanus-prone injuries.

Adult patients with tetanus in Slovenia 2006-2021 : Results of a national cohort study.

INTRODUCTION: The aim of the present study was to determine the demographic, epidemiological and clinical characteristics of adult patients with tetanus in Slovenia between 2006 and 2021, as well as to determine the therapeutic approaches which have been successfully used in the intensive care unit (ICU) of the Infectious Diseases Department in the University Medical Centre Ljubljana (UMC). METHODS: We included all adult patients who were treated for tetanus in the ICU of the Department of Infectious Diseases Ljubljana between January 1st, 2006, and December 31th, 2021, in the retrospective study. Available epidemiological and clinical characteristics were reviewed from the medical documentation. RESULTS: There were 31 patients included in the study, four (12.9%) males and 27 (87.1%) females. The vast majority of patients required mechanical ventilation (MV) (87.1%) which lasted (±â€¯SD) on average 35.4 ±â€¯16.0 days. Autonomic dysfunction was present in 29 (93.5%) patients and was statistically significantly associated with shorter disease evolution (p = 0.005) and presence of healthcare-associated infection (p = 0.020). During the hospitalization, 27 (87.1%) patients acquired at least one healthcare-associated infection, most commonly ventilator-associated pneumonia. The average length of stay in the ICU (±â€¯SD) was 42.5 ±â€¯21.3 days. With increasing age, MV lasted statistically significantly longer (p = 0.001), length of stay was longer (p = 0.015), and healthcare-associated infections occurred (p = 0.003) more frequently. Four patients (12.9%) died. CONCLUSIONS: Although the tetanus incidence rate in Slovenia is high in comparison to other European countries on average, our therapeutic approach resulted in a good survival rate and low mortality.

Generalized tetanus: a pediatric case report and literature review.

Pediatric tetanus is a rare and forgotten disease in countries with high childhood tetanus toxoid vaccination rates. Therefore, the clinical manifestations, treatment and management of this potentially life-threatening disease are not well known. With a literature review and discussion of tetanus management in pediatric patients, we describe a clinical course of a rare and fatal but vaccine-preventable disease, the generalized tetanus, in an adolescent who was successfully treated.

[Writhing Tongue: A Film About the Medical Practices, Anxiety, and Confusion Surrounding Tetanus in the 1970's].

The movie Writhing Tongue (1980), directed by Yoshitaro Nomura, accurately depicts the medical practices surrounding tetanus 50 years ago. The actress, who played five-year-old Masako, skillfully portrayed the common symptoms associated with tetanus. Treatment had continued under medical environment, medical devices, and the use of medicines in 1970. In the film, the patient's medical condition gradually worsens, leading to an increase in her parents' anxiety and fear. Classical music is used to dramatize specific scenes. In this manuscript, comparisons between historical and current medical care for tetanus are summarized, along with the history and epidemiology of tetanus. The onset of tetanus in wide-area disasters and in daily life, and medical trials are also summarized. Finally, vaccination as a preventative measure is discussed.

Tetanus, analysis of 29 cases

BackgroundTetanus disease is caused by Clostridium tetani, an anaerobe bacteria found in dust and soil. Once reached human body through damaged tissues, C. tetani releases several neurotoxins which block the inhibitory function, leading to an increased muscle tone, ultimately causing respiratory failure. Severe tetanus is a life-threatening disease, especially in low-income-regions.MethodsThis is a retrospective case-series study, undertaken at two hospitals of Vigo (population area 600,000 inhabitants). Tetanus cases were identified through the discharge databases of both hospitals between the years 1995–2019. Epidemiological and clinical data were obtained from the patient's medical records.ResultsA total of 33 cases were identified; median age was 67 years, and most of patients were women (n=16, 55.2%). Generalized tetanus was the most common clinical course, and neck stiffness was the most frequent symptom. A total of 25 patients (86%) were admitted to the Intensive Care Unit, 21 required invasive ventilation and 2 patients died.DiscussionThe incidence of tetanus was low but most of cases were severe. Mortality was slightly higher than previously reported. Interestingly, the deceased patients were old-women, consistent with previously reported research in high-income-regions, while mortality in low-income-countries concentrates in middle-aged men. (AU)

IntroducciónEl tétanos es causado por Clostridium tetani, bacteria anaerobia, ubicada en el suelo. Este microorganismo penetra a través de heridas y libera neurotoxinas que bloquean la función inhibitoria, produciendo espasticidad y fracaso respiratorio. Es una enfermedad grave, especialmente en regiones empobrecidas.MétodosSerie de casos realizada en dos hospitales vigueses (área 600.000 habitantes). Los casos fueron identificados mediante los sistemas de codificación entre 1995-2019. Los datos asistenciales se obtuvieron de la historia clínica.ResultadosSe identificaron 33 casos, mediana de edad, 67 años, la mayoría mujeres (n = 16, 55,2%). El tétanos generalizado fue la forma clínica predominante, la rigidez cervical el síntoma más común. Un total de 25 pacientes requirieron ingreso en UCI, 21 ventilación mecánica, dos fallecieron.DiscusiónEl número de casos fue bajo, pero la mayoría graves. La mortalidad fue ligeramente superior a la informada previamente. La mortalidad se concentró en mujeres ancianas, concordante con otros países desarrollados, mientras que la mortalidad en regiones no-desarrolladas se agrupa en varones de mediana edad. (AU)

Direct Medical Costs of Tetanus, Dengue, and Sepsis Patients in an Intensive Care Unit in Vietnam.

Background: Critically ill patients often require complex clinical care by highly trained staff within a specialized intensive care unit (ICU) with advanced equipment. There are currently limited data on the costs of critical care in low-and middle-income countries (LMICs). This study aims to investigate the direct-medical costs of key infectious disease (tetanus, sepsis, and dengue) patients admitted to ICU in a hospital in Ho Chi Minh City (HCMC), Vietnam, and explores how the costs and cost drivers can vary between the different diseases. Methods: We calculated the direct medical costs for patients requiring critical care for tetanus, dengue and sepsis. Costing data (stratified into different cost categories) were extracted from the bills of patients hospitalized to the adult ICU with a dengue, sepsis and tetanus diagnosis that were enrolled in three studies conducted at the Hospital for Tropical Diseases in HCMC from January 2017 to December 2019. The costs were considered from the health sector perspective. The total sample size in this study was 342 patients. Results: ICU care was associated with significant direct medical costs. For patients that did not require mechanical ventilation, the median total ICU cost per patient varied between US$64.40 and US$675 for the different diseases. The costs were higher for patients that required mechanical ventilation, with the median total ICU cost per patient for the different diseases varying between US$2,590 and US$4,250. The main cost drivers varied according to disease and associated severity. Conclusion: This study demonstrates the notable cost of ICU care in Vietnam and in similar LMIC settings. Future studies are needed to further evaluate the costs and economic burden incurred by ICU patients. The data also highlight the importance of evaluating novel critical care interventions that could reduce the costs of ICU care.

Tetanus, analysis of 29 cases.

BACKGROUND: Tetanus disease is caused by Clostridium tetani, an anaerobe bacteria found in dust and soil. Once reached human body through damaged tissues, C. tetani releases several neurotoxins which block the inhibitory function, leading to an increased muscle tone, ultimately causing respiratory failure. Severe tetanus is a life-threatening disease, especially in low-income-regions. METHODS: This is a retrospective case-series study, undertaken at two hospitals of Vigo (population area 600,000 inhabitants). Tetanus cases were identified through the discharge databases of both hospitals between the years 1995-2019. Epidemiological and clinical data were obtained from the patient's medical records. RESULTS: A total of 33 cases were identified; median age was 67 years, and most of patients were women (n=16, 55.2%). Generalized tetanus was the most common clinical course, and neck stiffness was the most frequent symptom. A total of 25 patients (86%) were admitted to the Intensive Care Unit, 21 required invasive ventilation and 2 patients died. DISCUSSION: The incidence of tetanus was low but most of cases were severe. Mortality was slightly higher than previously reported. Interestingly, the deceased patients were old-women, consistent with previously reported research in high-income-regions, while mortality in low-income-countries concentrates in middle-aged men.

Application of noninvasive positive pressure ventilation to respiratory complications of severe tetanus: a case report.

Respiratory failure because of muscle spasms is a major sequela of tetanus. Spasms can be controlled with sedation and adjunctive treatment, albeit at the expense of respiratory drive and weakness. Invasive ventilation under deep sedation with intensive care unit admission is the best practice. Where invasive ventilation is unavailable and when patients decline intubation, the management of muscle spasms and respiratory failure is extremely limited, with low survival rates. Herein, we present a case of severe tetanus in a 90-year-old female farmer who declined intubation and whose respiratory failure was managed with noninvasive positive pressure ventilation (NPPV) with a moderate dose of continuous benzodiazepine infusion to treat spasms. Compared with invasive ventilation, NPPV reduces the duration of ventilatory support and the risk of nosocomial pneumonia. Because spontaneous respiratory drive of the patient was maintained to trigger ventilation, pressure control ventilation was initiated. In previous references to tetanus management, the application of NPPV has not been mentioned. NPPV is a treatment option for patients with tetanus who are not intubated owing to limited medical resources or do-not-intubate orders for older patients.

Don't Be a Stiff: A Review Article on the Management of Tetanus.

Vaccine-preventable diseases, such as tetanus, are oftentimes a thought of the past in countries that only see a handful of cases per year. In recent years, though, there has been more controversy around vaccinations and fewer individuals getting vaccinated. This movement has resulted in vaccine-preventable diseases resurfacing (e.g., measles). Tetanus is one of the diseases that health care providers should continue to be familiar with in regard to its clinical presentation and the treatments that are available to manage the corresponding signs and symptoms. Because tetanus is an acute, toxin-mediated illness that can be fatal, prevention and treatment are critical. This article briefly summarizes tetanus and the therapies considered to be first line in its management.

Tétanos generalizado en un adolescente / Spread tetanus in an adolescent

Se presenta el caso clínico de un adolescente de 13 años de edad, con antecedentes de buena salud, quien solo recibió inmunización durante la etapa neonatal, el cual sufrió una herida causada por un clavo enmohecido en el dorso del pie derecho y acudió al Hospital Wete de Zanzíbar, Tanzania, por presentar dolores musculares, espasmos generalizados, risa sardónica y trismo, por lo cual se le diagnosticó tétanos generalizado. Se prescribió tratamiento médico con hidratación parenteral, toxina antitetánica, toxoide tetánico, antibióticos, sedantes y curación local de dicha herida. Luego de 2 meses de hospitalización el paciente tuvo una evolución satisfactoria.

The case report of a 13 years adolescent, with history of good health who just received immunization during the neonatal period is presented. He suffered from a wound caused by a rusty nail in the back of the right foot and he went to the Wete Hospital in Zanzibar, Tanzania, presenting muscular pains, spread spasms, sardonic laugh and trismus, reason why he was diagnosed spread tetanus. Treatment was prescribed with parenteral hydration, anti-tetanus toxin, anti-tetanus toxoide, antibiotics, sedative and total cure of this wound. After 2 months of hospitalization the patient had a favorable clinical course.

MANAGEMENT OF MEDICAL COMPLICATIONS ASSOCIATED WITH A PRESUMED TETANUS INFECTION IN A NORTHWEST BORNEAN ORANGUTAN (PONGO PYGMAEUS PYGMAEUS).

An 18-yr-old female orangutan (Pongo pygmaeus pygmaeus) developed opisthotonus after sustaining conspecific bite wounds 3 wk earlier. The orangutan developed progressive tetraparesis and dysphagia, despite normal mentation, suggestive of tetanus. A tetanus vaccine had been administered at 2 yr of age, but none since. Brain magnetic resonance imaging, computed tomography, cerebral spinal fluid tap, and bloodwork were unremarkable. Viral, Baylisascaris, and tetanus toxin testing were negative. A femoral central venous catheter (CVC) was placed to provide medications, fluids, and parenteral nutrition. The orangutan received human tetanus immunoglobulin, tetanus toxoid, penicillin, methocarbamol, and analgesia. After 1 wk, the catheterized limb became edematous; a deep vein thrombosis (DVT) was diagnosed ultrasonographically. A cephalic CVC was placed, the limb casted, intravenous therapy reinitiated, and enoxaparin started. The orangutan became mobile days later, and progressively improved. Despite no compliance with enoxaparin, the DVT resolved without residual signs. This is the first reported case of presumptive tetanus and DVT in a great ape.

Non-surgical treatment of tetanus infection associated with breast cancer skin ulcer: a case report and literature review.

BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.

[Localised tetanus with no obvious entry site: about a case in Bamako (Mali)]. / Tétanos localisé sans porte d´entrée apparente: à propos d´un cas à Bamako (Mali).

Tetanus is a major public health problem in sub-Saharan Africa. Localised tetanus is rare, unlike generalized tetanus which has been sufficiently described in the literature. We report a case of localised tetanus with no obvious entry site managed in the Department of Infectious Diseases in Bamako. The study involved a retired nurse aged 59 years who had not undergone tetanus booster immunisation within the last 10 years, corresponding to the date of her last delivery. She was referred to our Hospital with dysphagia associated with inability to open the buccal cavity. Patient's history was characterized by long-term therapy associated with many specialized consultations without any improvement. The diagnosis of localised tetanus with no obvious entry site was retained after having excluded any other local disorder. Outcome was favorable ten days after adequate management. Underdiagnosed or unknown to health-care providers, localised tetanus may mimic other diseases delaying diagnosis and management. Targeted campaign to build awareness should be implemented in order to improve adherence with immunization schedules.

Multicenter Study of Tetanus Patients in Fujian Province of China: A Retrospective Review of 95 Cases.

BACKGROUND: Tetanus is a life-threatening disease in developing countries and is accompanied by a high mortality rate. Although China is the world's largest developing country, there have been few clinical studies on tetanus in China. The purpose of this study was to investigate the epidemiology, incidence, and management of tetanus in Fujian Province and to understand the current treatment and prognosis of tetanus patients. METHODS: This was a retrospective, multicenter observational study of patients who presented with a clinical diagnosis of tetanus at 5 general hospitals in Fujian from January 2008 to December 2018. Data were analyzed using a computer software system. RESULTS: A total of 95 patients were recruited, including 6 newborns. The average age of the adult tetanus patients was 55.53 ± 15.39 years old. None of the patients knew their previous history of tetanus immunization. The rate of having received human tetanus immunoglobulin (HTIG) was 9.47%. A total of 73 (76.84%) patients were cured, 17 (17.89%) patients had an unknown prognosis, and 5 (5.26%) patients died. Age, severity of illness, and complications all increased the total duration of hospitalization. Compared with endotracheal intubation, tracheotomy increased the length of stay in the ICU (Intensive Care Unit) but did not affect the total hospital length of stay for mechanical ventilation. CONCLUSIONS: With the promotion of nationwide immunization against tetanus and the development of critical care medicine, morbidity and mortality rates of tetanus in Fujian are low. It is important to increase awareness among local physicians and staff in charge of tetanus immunization programs and with regard to neonatal tetanus and drug-induced tetanus. The prevention and treatment of tetanus in developing countries should arouse widespread concern in society.

[Specifications for diagnosis and treatment of non-neonatal tetanus].

Tetanus consists of neonatal tetanus and non-neonatal tetanus. Non-neonatal tetanus remains a serious public health problem, although neonatal tetanus has been eliminated in China since 2012. Non-neonatal tetanus is a potential fatal disease. In the absence of medical intervention, the mortality rate of severe cases is almost 100%. Even with vigorous treatment, the mortality rate is still 30%-50% globally. These specifications aim to regulate non-neonatal tetanus diagnosis and treatment in China, in order to improve medical quality and safety. These specifications introduce the etiology, epidemiology, pathogenesis, clinical manifestations and laboratory tests, diagnosis, differential diagnosis, grading and treatment of non-neonatal tetanus.

Demography and Symptom Profile of Tetanus: A Cross-sectional Observation in an Infectious Disease Hospital of Bangladesh.

Tetanus is a potentially preventable neurological infectious disorder with paucity of literature in Bangladesh. We aimed to see the demography and symptom profile of tetanus cases managed at the Infectious disease Hospital Sylhet. This hospital based cross-sectional descriptive study was conducted within the time period of January to December 2012 among 50 consecutive admitted patients in the Infectious Disease Hospital, Sylhet, Bangladesh who were diagnosed as a case of tetanus and fulfilling the inclusion criteria and exclusion criteria. Neonatal tetanus was considered as exclusion criteria and clinical diagnosis of tetanus was considered as the tetanus. Data were collected purposively with pretested predesigned questionnaire. Data were processed manually and analyzed with the help of SPSS Version 16.0. The mean±SD age was 33.00±16.8 years, ranging from 10 to 70 years. Among the 50 respondents, 72.0% were male, 50% from lower class, 34% were students and 30.0% had their educational status of primary level, 60.0% from rural social background. Trismus was found in 98.0% of the cases, rigidity in 96.0% cases, body ache in 94.0% cases, dysphagia in 92.0% cases, neck pain in 78.0% cases, dysarthria in 92.0% cases, reflex spasm in 66.0% cases, opisthotonus in 46.0% cases and urinary retention in 26.0% cases. In this study rural male people with lower socioeconomic status individuals were mostly affected with trismus, rigidity, body ache and dysphagia symptoms.

Neonatal tetanus in eastern Uganda: improved outcome following the implementation of a neonatal tetanus protocol.

Neonatal tetanus remains a significant, yet avoidable, cause of neonatal death. Despite the 34,000 deaths that occur globally from neonatal tetanus every year, there has been little research into the management of neonatal tetanus. Until worldwide elimination of neonatal tetanus is achieved, the case management of this devastating illness needs to be improved. We describe an improved outcome of neonatal tetanus following the introduction of a neonatal tetanus protocol including diazepam, magnesium sulphate, bubble continuous positive airway pressure and broad-spectrum antibiotics in a low-resource setting in eastern Uganda.