Chapter 133. Tetanus (Part 3) pps

Chapter 133. Tetanus (Part 3) Vaccine Patients recovering from tetanus should be actively immunized (see below) because immunity is not induced by the small amount of toxin required to produce disease. Additional Measures Like all patients receiving ventilatory support, patients with tetanus require attention to hydration; nutrition; physiotherapy; prophylactic anticoagulation; bowel, bladder, and renal function; decubitus ulcer prevention; and treatment of intercurrent infection. Prevention Active Immunization All partially immunized and unimmunized adults should receive vaccine, as should those recovering from tetanus. The primary series for adults consists of three doses: the first and second doses are given 4–8 weeks apart, and the third dose is given 6–12 months after the second. A booster dose is required every 10 years and may be given at mid-decade ages—35, 45, and so on. Combined tetanus and diphtheria toxoid, adsorbed (Td, for adult use)—rather than single-antigen tetanus toxoid—is preferred for persons >7 years of age. Adsorbed vaccine is preferred because it produces more persistent antibody titers than fluid vaccine. Two combined tetanus/diphtheria/attenuated pertussis vaccines have recently been approved: one (ADACEL) for adults 19–64 years of age and the other (BOOSTRIX) for adolescents 11–18 years of age. The Advisory Committee on Immunization Practices has recommended a single dose of Tdap (ADACEL) for adults 19–64 years old who have not received Tdap. Wound Management Proper wound management requires consideration of the need for (1) passive immunization with TIG and (2) active immunization with vaccine (Tdap or Td; Table 133-1). The dose of TIG for passive immunization of persons with wounds of average severity (250 units IM) produces a protective serum antibody level for at least 4–6 weeks; the appropriate dose of TAT, an equine-derived product, is 3000–6000 units. Vaccine and antibody should be administered at separate sites with separate syringes. Table 133-1 Guide to Tetanus Prophylaxis a nd Routine Wound Management Clean Minor Wound All Other Wounds a History of Adsorbed Tetanus Toxoid (Doses) Tdap or Td b TIG Tdap or Td b TIG Unknown or <3 Yes No Yes Yes ≥3 No c No No d No a Such as, but not limited to, wounds contaminated w ith dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds from missile or crushing injuries, burns, and frostbite. b Tdap is preferred to Td for adults 19– 64 years old who have never received Tdap. Td is preferred for adults who have receive d Tdap previously and is used when Tdap is not available. Td is also recommended for persons >64 years old. If TT and TIG are both used, TT adsorbed rather than TT for booster use only (fluid vaccine) should be used. c Yes, if ≥10 years have elapsed since the last TT-containing vaccine dose. d Yes, if ≥5 years have elapsed since the last TT-containing vaccine dose. Note: Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed; DT, diphth eria and tetanus vaccine; DTP, diphtheria, tetanus, and pertussis vaccine; Td, tetanus- diphtheria toxoid, adsorbed; TIG, tetanus immune globulin; TT, tetanus toxoid. Source: Modified from Centers for Disease Control and Prevention, 2006. Neonatal Tetanus Preventive measures include maternal vaccination, even during pregnancy; efforts to increase the proportion of births that take place in the hospital; and the provision of training for nonmedical birth attendants. Prognosis The application of methods to monitor and support oxygenation has markedly improved the prognosis in tetanus. Mortality rates as low as 10% have been reported from units accustomed to handling such cases. In the United States in 2003, there were 20 cases and 2 deaths; no cases were in patients <18 years old, and 19 cases were ascribed to inadequate immunization. The outcome is poor in neonates and the elderly and in patients with a short incubation period, a short interval from the onset of symptoms to admission, or a short period from the onset of symptoms to the first spasm (period of onset). Outcome is also related to the extent of prior vaccination. The course of tetanus extends over 4–6 weeks, and patients may require prolonged ventilator support. Increased tone and minor spasms can last for months, but recovery is usually complete. Further Readings Abrutyn E, Berlin JA: Intrathecal therapy of tetanus: A meta- analysis. JAMA 266:2262, 1991 [PMID: 1833565] Ahmadsyah I, Salim A: Treatment of tetanus: An open study to compare the efficac y of procaine penicillin and metronidazole. BMJ 291:648, 1985 [PMID: 3928066] Bleck TP: Clostridium tetani (tetanus), in Principles and Practice of Infectious Diseases, 5th ed, GL Mandell et al (eds). New York, Churchill Livingstone, 2000, pp 2537–2543 Centers for Disease Control and Prevention: Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: Recommendations of the Advisory Committee on Immunization Practices ( ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR 55(RR17):1, 2006 Centers for Disease Control and Prevention: Tetanus—Puerto Rico, 200 2. MMWR 51:613, 2002 ———: Tetanus surveillance—United States, 1998– 2000. Surveillance summaries, June 20, 2003. MMWR 52(SS-3):1, 2003 Cook TM et al: Tetanus: A review of the literature. Br J Anaesth 87:477, 2001 [PMID: 11517134] Hsu SS et al: Tetanus in the emergency department: A current review. J Emerg Med 20:357, 2001 [PMID: 11348815] McQuillan CM et al: Serologic immunity to diphtheria and tetanus in the United States. Ann Intern Med 136:660, 2002 [PMID: 11992301] Thwaites CL et al: Magnesium sulphate for the treatment of severe tetanus: A randomized controlled trial. Lancet 368:1436, 2006 [PMID: 17055945] Bibliography Bardenheier B et al: Tetanus surveillance—United States, 1995– 1997. MMWR 47:1, 1998 [PMID: 9665156] Bruggemann H et al: The genome sequence of Clostridium tetani, the causative agent of tetanus disease. Proc Natl Acad Sci USA 100:1316, 2003 [PMID: 12552129] Farrar JJ et al: Tetanus. J Neurol Neurosurg Psychiatry 69:292, 2000 [PMID: 10945801] Lee DC, Lederman HM: Anti-tetan us toxoid antibodies in intravenous gamma globulin: An alternative to tetanus immune globulin. J Infect Dis 166:642, 1992 [PMID: 1500750] Sanford JP: Tetanus— forgotten but not gone. N Engl J Med 332:812, 1995 [PMID: 7862186] Turton K et al: Botulinum and tetanus neurotoxins: Structure, function and therapeutic utility. Trends Biochem Sci 27:552, 2002 [PMID: 12417130] Wesley AG, Pather M: Tetanus in children: An 11- year review. Ann Trop Paediatr 7:32, 1987 [PMID: 2439001] Y en JM et al: Role of quinine in the high mortality of intramuscular injection tetanus. Lancet 344:786, 1994 [PMID: 7916074] . Chapter 133. Tetanus (Part 3) Vaccine Patients recovering from tetanus should be actively immunized (see below) because immunity. Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed; DT, diphth eria and tetanus vaccine; DTP, diphtheria, tetanus, and pertussis vaccine; Td, tetanus- diphtheria. Prevention: Tetanus Puerto Rico, 200 2. MMWR 51:613, 2002 ———: Tetanus surveillance—United States, 1998– 2000. Surveillance summaries, June 20, 2003. MMWR 52(SS -3): 1, 2003 Cook TM et al: Tetanus: