Prognosis in tetanus: Use of data from therapeutic trials

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 (± SD) on average 35.4 ± 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 (± SD) was 42.5 ± 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.

Tetanus

Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.

O tétano como doença de base para disfagia

TEMA: disfagia e tétano. OBJETIVO: apresentar revisão bibliográfica sobre a fisiopatologia do tétano e como a deglutição pode ser afetada por essa doença. CONCLUSÃO: apesar da pouca existência de bibliografia, que relacionem o tétano a disfagia, a pesquisa demonstrou que a deglutição pode ser afetada em todas as suas fases, inclusive a esofágica, devido à contratura muscular decorrente da ação da neurotoxina tetanopasmina.

Clinical classification of tetanus patients

The authors propose a clinical classification to monitor the evolution of tetanus patients, ranging from grade I to IV according to severity. It was applied on admission and repeated on alternate days up to the 10th day to patients aged > or = 12 years admitted to the State University Hospital, Recife, Brazil. Patients were also classified upon admission according to three prognostic indicators to determine if the proposed classification is in agreement with the traditionally used indicators. Upon admission, the distribution of the 64 patients among the different levels of the proposed classification was similar for the groups of better and worse prognosis according to the three indicators (P > 0.05), most of the patients belonging to grades I and II of the proposed classification. In the later reclassifications, severe forms of tetanus (grades III and IV) were more frequent in the categories of worse prognosis and these differences were statistically significant. There was a reduction in the proportion of mild forms (grades I and II) of tetanus with time for the categories of worse prognostic indicators (chi-square for trend: P = 0.00006, 0.03, and 0.00000) whereas no such trend was observed for the categories of better prognosis (grades I and II). This serially used classification reflected the prognosis of the traditional indicators and permitted the comparison of the dynamics of the disease in different groups. Thus, it becomes a useful tool for monitoring patients by determining clinical category changes with time, and for assessing responses to different therapeutic measures.

Predicting the clinical outcome of tetanus: the tetanus severity score

OBJECTIVES

To create a new tetanus score and compare it with the Phillips and Dakar scores.

METHODS

We used prospectively acquired data from consecutive patients admitted to the Hospital for Tropical Diseases, Ho Chi Minh City, to create the Tetanus Severity Score (TSS) with multivariate logistic regression. We compared the new score with Phillips and Dakar scores by means of resubstituted and prospective data, assessing performance in terms of sensitivity, specificity and area under receiver operator characteristic curves.

RESULTS

Resubstitution testing yielded a sensitivity of 77% (298/385) and a specificity of 82% (1,183/1,437) for the TSS; 89% (342/385) and 20% (281/1,437) for the Phillips score; and 13% (49/385) and 98% (1,415/1,437) for the Dakar score. The TSS showed greatest discrimination with 0.89 area under the receiver operator characteristic curve (95% CI 0.88-0.90); this was 0.74 for the Dakar score and (95% CI 0.71-0.77) and 0.66 for the Phillips score (95% CI 0.63-0.70; P values <0.001). Prospective testing showed 65% (13/20) sensitivity and 91% (210/230) specificity for the TSS; 80% (16/20) and 51% (118/230) for the Phillips score; and 25% (5/20) and 96% (221/230) for the Dakar score. The TSS achieved the greatest area under TSS of 0.89 (95% CI 0.82-0.96), significantly greater than the Phillips score [0.74 (0.6-0.88), P = 0.049] but not the Dakar score [0.80, (0.71-0.90), P = 0.090].

CONCLUSIONS

The TSS is the first prospectively developed classification scheme for tetanus and should be adopted to aid clinical triage and management and as a basis for clinical research.

Randomised controlled trial of tetanus treatment with antitetanus immunoglobulin by the intrathecal or intramuscular route

OBJECTIVE

To evaluate the effect of intrathecal therapy with human antitetanus immunoglobulin on clinical progression of and mortality from tetanus.

DESIGN

Randomised controlled trial.

SETTING

Intensive care unit of a university hospital, Pernambuco, Brazil.

PARTICIPANTS

120 patients with tetanus allocated to antitetanus immunoglobulin by either the intrathecal and intramuscular route (n = 58) or the intramuscular route (n = 62; control group).

MAIN OUTCOME MEASURES

Clinical progression of disease, duration of hospital stay, duration of occurrence of spasms, complications, respiratory infection, respiratory failure or mechanical ventilation, duration of respiratory assistance, and mortality.

RESULTS

Patients in the treatment group showed a better clinical progression than those in the control group (chi2 for trend 7.752, P = 0.005; difference in proportion of patients with improvement 20%, 95% confidence interval 4% to 35%). The duration of occurrence of spasms, hospital stay, and respiratory assistance were all shorter in patients the treatment group: respectively, 14.96, 0.0001 (difference in proportion of patients with spasms lasting < or = 10 days 36%, 18% to 55%); 4.56, 0.03; and 6.56, 0.01 (proportion of patients who needed assistance for < or = 10 days 69.2% in the treatment group and 30.8% in the control group (difference 38%, 12% to 65%)).

CONCLUSION

Patients treated with antitetanus immunoglobulin by the intrathecal route show better clinical progression than those treated by the intramuscular route.

Identification of risk factors for death from tetanus in Pernambuco, Brazil: a case-control study

A case-control study was conducted to identify risk factors for death from tetanus in the State of Pernambuco, Brazil. Information was obtained from medical records of 152 cases and 152 controls, admitted to the tetanus unit in the State University Hospital, in Recife, from 1990 to 1995. Variables were grouped in three different sets. Crude and adjusted odds ratios, p-values and 95% confidence intervals were estimated. Variables selected in the multivariate analysis in each set were controlled for the effect of those selected in the others. All factors related to the disease progression - incubation period, time elapsed between the occurrence of the first tetanus symptom and admission, and period of onset - showed a statistically significant association with death from tetanus. Similarly, signs and/or symptoms occurring on admission or in the following 24 hours (second set): reflex spasms, neck stiffness, respiratory signs/symptoms and respiratory failure requiring artificial ventilation (third set) were associated with death from tetanus even when adjusted for the effect of the others.

Tongue piercing. The new "rusty nail"?

BACKGROUND

Cephalic tetanus is a rare form of the tetanus caused primarily by wounds or other infectious processes involving the head and neck. This condition frequently progresses to the generalized form of tetanus with the attendant risks and complications.

METHODS

A case report of a young female who developed an unusual form of tetanus after a tongue piercing is presented here. We discuss this disorder as it applies to the contemporary caregiver with a focus on its presentation and recognition.

RESULTS

A delay in diagnosis of 13 days from presentation occurred. The patient had a slow, uneventful but incomplete recovery course. She never developed significant airway compromise, nor did she demonstrate any evidence of hemodynamic instability but continued to have right facial weakness up to 6 months after discharge.

CONCLUSIONS

A few factors were identified that contributed to the significant delay in diagnosis. The unusual nature of the disease and a lowered index of suspicion on the part of the initial caregivers were probably the major causes. Fortunately, no major adverse sequelae resulted from the delay. However, if this case heralds the onset of a rise in the incidence of tetanus, early recognition and diagnosis would seem essential to avoid much of the morbidity and mortality associated with the disease.

Tetanus as a cause of acute renal failure: possible role of rhabdomyolysis

To study the frequency and examine the role of rhabdomyolysis in the acute renal failure in tetanus 18 patients with the diagnosis of generalized tetanus consecutively admitted to the infectious disease hospital were evaluated. Of these 14 were male and 4 female with mean age of 31.8 +/- 2.0 years. Except for mild proteinuria recorded in 9 patients, the urinalysis were unremarkable. Serum creatinine higher than 1.4mg/dl was recorded in 39% of the patients, abnormal levels of CPK in 87,5% and serum myoglobin greater than 120 micrograms/l in 39% of the patients. Oliguria was documented in one patient and none required dialysis therapy. No correlation was found between renal failure and myoglobin and/or CPK serum levels. Acute renal failure in tetanus was not infrequent; usually it was non-oliguric, mild and transient and not related to the severity of the disease or to serum levels of myoglobin and/or CPK.

Factors affecting prognosis of neonatal tetanus

Neonatal tetanus is associated with a high mortality rate, despite intensive care. Although it can be prevented by immunization of expectant mothers and by good hygiene and asepsis during delivery, neonatal tetanus is still a common cause of neonatal mortality in underdeveloped countries. In our study, hospital records of 133 newborns with neonatal tetanus were evaluated to identify the possible factors affecting prognosis of neonatal tetanus; 79 were males and 56 females, and 54 (41.6%) of the 133 died. Sex and birth weight did not affect the prognosis. As a result of our study, we found that age on admission < 10 days, symptoms < 5 days and presence of risus sardonicus and fever indicate a poor prognosis in neonatal tetanus.

Pulmonary Manifestations of Neurological Disease

Breathing is a complicated act that requires sophisticated control mechanisms. The nervous system coordinates 3 fundamentally important components of respiration. The central nervous system has a central pattern generator that, along with appropriate feedback mechanisms, establishes both the resiratory rate and the depth of respirations. The peripheral nervous system facilitates transmission of these respiratory commands to the ventilatory muscles. The nervous system also contributes to the control of airway size. Laryngeal function is coordinated with inspiration, and local nerves in the lung have a major role in determining bronchial patency. Finally, the nervous system acts in incompletely understood ways to regulate perfusion of the lungs and to match local pulmonary blood flow with ventilation. Failure of the nervous system to adequately control these 3 different aspects of respiration may result in lifethreatening illness. Understanding how the nervous system affects control of ventilation, airway patency, and pulmonary perfusion therefore will enable intensivists to recognize and manage the pulmonary complications of neurological disease.

Use of esmolol to control autonomic instability of tetanus

Tetanus is often accompained by autonomic instability, rendering hemodynamic management difficult. Death is frequently secondary to an inability to control this instability. A variety of modalities have been used to stabilize the cardiovascular system, but all are not ideal. Esmolol offers theoretical advantages over other modalities. We report a case of severe tetanus in which a continuous infusion of esmolol was effective in controlling the autonomic instability.

Epidemiology of tetanus in Finland from 1969 to 1985

During the period 1969-85, tetanus caused the hospitalization of 106 patients (63 men and 43 women) in Finland. 12 (11.3%) of them died, most of the causes of death being unexpected complications during the intensive care. The majority of the patients were more than 50 years old and had not been fully vaccinated against tetanus. There was a clear seasonal variation, most of the cases occurring during the months when there is no snow on the ground. Half of the primary lesions were minor injuries to hands and fingers. Only half of the primary lesions had needed medical treatment and usually the patients had received antibiotics and tetanus vaccination but not immunoglobulin. To diagnose tetanus is more difficult today than previously, because few doctors nowadays encounter tetanus cases and the diagnosis is based entirely on clinical criteria, and because abortive mild forms of tetanus may occur, especially in patients with partial immunity.

Diverse prognosis in metastatic breast cancer: who should be offered alternative initial therapies?

In an attempt to clarify appropriate treatment options for women with stage IV breast cancer, we studied the survival experience of a large dataset of patients treated on Cancer and Leukemia Group B (CALGB) protocols. The study, restricted to women who had had no prior chemotherapy for metastatic disease, demonstrated a surprisingly poor prognosis, with an estimated median survival of 1.6 years and only 26% alive at 3 years. Analysis of prognostic factors permitted the identification of subsets with even shorter survival, such as women with estrogen receptor negative tumor in more than one metastatic site and prior adjuvant chemotherapy. We feel that an evaluation of intensive investigational treatment approaches, such as trials using autologous bone marrow transplantation, is justified for most stage IV breast cancer patients, in view of their poor prognosis.

Cephalic tetanus: a case report and review of the literature

Cephalic tetanus is a rare form of tetanus defined as trismus plus paralysis of one or more cranial nerves. The most frequently involved cranial nerve is the seventh. It accounts for 1 to 3% of the total number of reported cases of tetanus and has a mortality of 15 to 30%. The incubation period is 1 to 14 days, and approximately two thirds of cases progress to generalized tetanus. The mechanism of the paralysis is not completely understood. Treatment involves debridement of wounds, administration of penicillin and tetanus immune-globulin, aggressive supportive care, and initiation of active immunization.

Long-term continuous spinal anesthesia in severe tetanus with autonomic disturbance

The mortality rate from tetanus is still high if the disease is accompanied by signs of autonomic nervous system dysfunction. We treated a 75-year-old woman with tetanus and autonomic dysfunction with continuous high spinal anesthesia for 23 days. She recovered. Spinal anesthesia may be a useful adjunct for the treatment of severe tetanus.

Tetanus neonatorum--experience with intrathecal serotherapy at Muhimbili Medical Centre, Dar es Salaam, Tanzania

In an attempt to lower the mortality rate of neonatal tetanus a study was undertaken to determine whether intrathecal serotherapy influences mortality from this disease. Sixty-six babies with tetanus neonatorum were studied. The mortality rate among babies who received intrathecal anti-tetanus serum (ATS) was 45% compared with 82% in the control group given intramuscular ATS (P congruent to 0.002). Infants who received intrathecal ATS also had fewer complications than controls (P less than 0.001) and the duration of hospital stay for the survivors was 19.3 days compared with 28.7 days for the control group (P less than 0.05). It is concluded that intrathecal ATS is superior to intramuscular ATS in the treatment of neonatal tetanus.

Booster immunisation for diphtheria and tetanus: no evidence of need in adults

Recommendations to give adults diphtheria and tetanus toxoid every ten years have been based on serological surveys that have shown lower antibody levels in older populations. The purpose of an immunisation programme, however, is to prevent disease and not merely to produce antibodies. In Canada, although an immunisation programme against diphtheria has been in operation for nearly sixty years, age-specific morbidity and mortality rates for diphtheria do not show an increase with age. Similarly, age-specific death rates from tetanus do not show any increase. From Canadian surveillance data, there is no evidence to suggest that people are leaving the immune pool and entering the susceptible pool. Immunisation programmes do not need to include routine administration of booster doses of diphtheria and tetanus toxoids to adults since the benefits of the procedure do not justify the risks or costs. Continuing case-surveillance will bring to light any increase in incidence of disease justifying a need for an adult programme.