Objectives: To determine various prognostic factors in tetanus patients during the period 2016 - 2017. Subjects: 64 patients were diagnosed tetanus, ages over 17, treated in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases from June, 2016 to April, 2017.
Journal of military parmaco-medicine n07-2017 A CLINICAL RETROSPECTIVE STUDY OF PROGNOSTIC FACTORS IN TETANUS PATIENTS (2016 - 2017) Hoang Vu Hung*; Nguyen Lan Phuong*; Dinh Thi Phuong Lien* Han Minh Thuy**; Hoang Thi Thanh**; Luu Thi Nhan** SUMMARY Objectives: To determine various prognostic factors in tetanus patients during the period 2016 - 2017 Subjects: 64 patients were diagnosed tetanus, ages over 17, treated in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases from June, 2016 to April, 2017 Method: The cross-sectional retrospective, descriptive study Results: A total of the 64 patients with diagnosis of tetanus, had 53 male (70.31%) and 15 female (29.69%) The mean age was 58.7 ± 15.7 years (range 18 - 94) The outcomes of treatment were divided into two groups: patients with dead, severe disease and 57 survivors There was a significant difference between two groups in patients with dead and more severe disease and cured patients observed in relation to more severe prognostic factors were the incubation period < 14 days and period of onset within 24 hours, site of infection, the number of convulsion over 10 seizures, frequency of pulse with p< 0.05 Conclusions: In this study, we determined severe prognostic factors of tetanus disease included the time of onset within 24 hours; level of lockjaw lesser cm; over 10 convulsions within 24 hours; increase of sputum and sweat; frequency of pulse over 110 cycles per minute * Keywords: Tetanus; Prognostic factors; 2016 - 2017 INTRODUCTION Tetanus is a severe infectious disease caused by the exotoxin produced by Clostridium tetani The widespread use of tetanus vaccine in prophylaxis programs has led significantly decline in incidence, but tetanus disease remains to be an important public health problem associated with high mortality all over the world, especially in developing countries [6, 8] Therefore, it is very crucial to identify valuable prognostic factors of tetanus to reduce the mortality rate In 1975, DarkaSenegal, International Conference on tetanus disease gave a consensus including six important prognostic factors: the period of incubation and the time of onset, the presence of muscle spasms, the port of entry, the level of fever, the frequency of pulse [7] However, diagnosis of tetanus is main clinical, whereas treatment is the best done, prognostic factors are showed above does still not reflect all the follow-up process of diseases So, it is very necessary to determine more sufficient factors for predicting tetanus disease Vietnam is a developing country with tropical climate, located in region of countries with high * 103 Military Hospital ** Vietnam Military Medical University Corresponding author: Hoang Vu Hung (dr.hoangvuhung@yahoo.com) Date received: 10/06/2017 Date accepted: 07/08/2017 132 Journal of military phrmaco-medicine nO7-2017 prevalence of tetanus Even though there were the Expanded Immunization Program and the advance of the treatment methods that helpe to minimize significantly the mortality rate of patients with diagnosis of tetanus, the treatment and prognosis of tetanus are still a great issue to be elucidated Because of the prolonged hospital stay, the high cost of treatment, and confronted complications or even death, tetanus remains major health problem and challenging Patients were divided into two groups according to the outcomes of treatment: 57 survivors and non-survivors: There were many tetanus patients admitted in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases From 2004 2009, Department of Infectious Diseases at 103 Hospital treated 36 patients with diagnosis of tetanus, the morality rate was observed 27.8% [5] In recent years, both two hospitals continues enrolled a lot of tetanus cases; but it is still lack of the comprehensive research reported to access about the clinical features, severe prognostic factors of diseases Therefore, this study is to: Point out severe prognostic factors of patients with tetanus during 2016 - 2017 Clinical data were recorded and data sheet was used to collect the following data: age, gender, address, occupation, risk factor, type and duration of presenting first symptoms, duration of hospital stay, physical signs, laboratory parameters, complication(s), mode of treatment, outcomes at hospital discharge and causes of death, time period of incubation (time from injury to the appearance of the first symptoms) and period of onset (interval between the first symptoms and the first spasm), the number of eclampsia and pulse frequency were determined SUBJECTS AND METHODS A total of the 64 patients aged > 17 years with diagnosis of tetanus, who admitted to the Department of Infectious Diseases of 103 Hospital and National Hospital of Tropical Diseases between June, 2016 and April, 2017 enrolled in this crosssectional descriptive study The study protocol was reviewed and approved by the institutional review board of 103 Hospital and National Hospital of Tropical Diseases * Inclusion criteria [1]: - Patients had suspicious wound with the point of entry - Clinical symptoms at onset of the first trismus, then skeletal muscles spasm of the head, neck, and trunk - Patients had percusive seizure with increased muscular tone Data were analyzed and compared between patients in group and group using SPSS 13.0 Chi-square test used for categorical variables or Fisher’s exact tests as appropriate and student’s t-tests and Mann - Whitney U test for quantitative variables Logistic regression was used to determine prognostic factors affecting deaths from tetanus disease To find some significant prognostic factors of tetanus, p values < 0.05 were considered as statistical significance 133 Journal of military parmaco-medicine n07-2017 RESULTS AND DISCUSSION General characteristics of patients Among 64 patients with tetanus, there were 45 male (70.31%) and 19 female (29.69%) The mean age was 58.7 ± 15.7 years (range 18 - 94), patients with the highest age was 94 years, whereas, the lowest age was 21 years Our data were comparable with studies reported by Truong Thi Dieu Minh (male/female ratio was 1.5/1) [2] and Nguyen Thi Tam observed male patients had higher threefold ages than female patients Severe prognostic factors in tetanus patients Patients with age > 60 years had higher fatality rate as compared with those under age > 60 years (85.71% vs 33.33%) However, this difference was not statistically significant with p > 0.05 We did not observe any differences between the two groups in relation to age group above These results were different from that of Hoang Tien Tuyen et al suggested that tetanus patients had closed wounds, ligaments, bruised, combined infection as a major prognostic factor in the outcome of tetanus treatment [5] This difference could be explained that it was associated with size of samples, patient characteristics and the time point at the beginning of the study The study observed most patients had the port of entry in soft tissue wound There was a statistically significant relationship with respect to the entry sites and outcomes of treatment Table 1: Association between age group and port of entry with treatment outcome Treatment Dead, severe disease Survivors p Outcome n % n % Aged group ≥ 60 < 60 85.71 19 33.33 14.29 38 66.67 Entry sites Soft tissue wound Non-soft tissue wound Unknown 57.14 29 50.88 42.86 23 40.35 0 8.77 > 0.05 > 0.05 The most common site of infection was lower limbs (37 of 64 patients), and head, body, upper limbs (22 of 64 patients), while patients were not identified site of injury Most patients with infection in lower limbs, head, body, upper limbs had higher cured rate compared deceased or severed patients However, there was a significant difference between two groups associated with infection sites observed In this study, 52 of 64 patients had received SAT injection after injury and among 12 patients had not been used SAT injection after trauma, patients died and more severe form of tetanus We had showed that a significant difference between died and survived patient groups in relation to SAT use status after injury 134 Journal of military phrmaco-medicine nO7-2017 Table 2: Relationship between sites of infection and the SAT injection status after injury with the outcome of treatment Treatment results Dead, severe disease p Survivors Number % Number % Site of infection Lower limbs Head, body, upper limbs Unknown 57.14 42.86 33 19 57.89 33.33 8.78 Injection SAT vaccination Yes No 100 52 91.23 8.77 > 0.05 < 0.05 100% of patients died and more severe disease had the period of incubation ≤ 14 days while patients cured had the period of incubation > 14 days There was a significant difference between the two groups observed Some authors found that patients with an incubation period of less than 14 days was prognostic factors of mortality [3, 7] In this study, 13 of 64 patients had a period of onset less 24 hours, whereas 51 patients with period of onset more than 24 hours prior to hospital admission The study results demonstrated a significant difference between two groups associated with the period of onset before and after 24 hours This result indicated a short period of onset less 24 hours was a predictor of disease Table 3: Relationship between incubation time and onset time with the outcome of treatment Treatment results Dead, severe disease % Number p Survivors Number % Incubation period (days) ≤ 14 >14 Unknown 0 100 0 40 12 70.18 21.05 8.77 Onset period (hours) ≤ 24 > 24 57.14 42.86 48 15.79 84.21 > 0.05 < 0.05 Table 4: Relationship between level of trismus and number of convulsion/24 hours with treatment results Treatment results Dead, severe disease Survivors p Number % Number % Level of trismus ≤ cm > cm 71.43 28.57 19 38 33.33 66.67 < 0.05 Number of convulsion ≤ 10 10 - 100 > 100 85.71 14.29 48 84.21 15.79 < 0.05 135 Journal of military parmaco-medicine n07-2017 In this study, we observed a significant association between two groups of patients died had a maximal trismus ≤ cm, with those cured (p < 0.05) In addition, there was a statistically significant between the two groups in relation to the number of convulsion observed As compared with studies reported by Nguyen Thi Tam, Nguyen Van Nhung indicated that tetanus patients with maximum less than cm had the highest mortality, the patients with trismus more than cm had no mortality [3, 4] Thus, at the onset period, monitoring and access the level of trismus had shown to be a prognostic significance Patients with stronger lockjaw had the higher the mortality or more severe disease 100% of patients died, and more severe illness, had the number of seizures within 24 hours were more than 10 seizures, whereas cured group was lesser than 10 seizures within 24 hours The difference between the two groups was statistically significant with p < 0.05, indicated that the number of seizures within 24 hours was a severe prognostic factor of tetanus disease Table 5: Relationship between increased sputum, sweating with the outcome of treatment Treatment results Increase sputum, sweating Dead, severe disease Survivors p Number % Number % Yes 100 38 66.67 > 0.05 No 0 19 33.33 < 0.05 100% of patients died and more severe disease had autonomic disregulation leading to increased sputum and perspiration, while cured group was 66.67% The difference between the two groups was statistically significant (p < 0.05) This data are also comparable with the results of Truong Thi Dieu Minh's study, patients with mortality rate had increased sputum and sweat were significantly higher than the control group (91.2% vs 22.4%, p < 0.05) [2] Table 6: Relationship between temperature and pulse frequencies at full-blast time with the outcome of treatment Treatment results Dead, severe disease Number % ≤ 37 C 3701 - 380C 38 - 39 C > 390C Survivors p Number % 14.28 15.79 14.28 17 29.82 42.86 25 43.86 28.58 10.53 > 110 cycles/min 71.43 18 31.58 ≤ 110 cycles/min 28.57 39 68.42 Temperature 0 > 0.05 Frequency pulses 136 < 0.05 Journal of military phrmaco-medicine nO7-2017 28.58% of patients died, severe illness had high fever with temperature > 39oC, higher than the group cured (10.53%) However, the difference between the two groups was not statistically significant with p > 0.05 Truong Thi Dieu Minh's study so found that patients with body temperature > 390C had a higher mortality rate, but not statistically significant when compared with the group control (60% vs 39.6%) [2] 71.43% of patients with fatal, severe disease, rapid pulse frequency > 110 cycles per minute, while cured patients were 31.58% The difference between two groups was a statistically significance with p < 0.05 Thus, the pulse frequency > 110 cycles/minute was a significant severe predictor for tetanus diseases CONCLUSION In conclusion, we studied 64 tetanus patients treated in the Department of Infectious Diseases of 103 Hospital and National Hospital of Tropical Diseases from June 2016 to April, 2017 to determine prognostic factors of tetanus disease This study result indicated that severe predictors of tetanus patients concluded: - The onset period was shorter than 24 hours - Trismus (the level of lockjaw) less than cm - Presence of over 10 convulsions within 24 hours - Increase of sputum and sweat - Frequency of pulse over 110 cycles per minute REFERENCES Department of Infectious Diseases - Military Medical University Tetanus, Infectious Diseases People's Army Publishing House Hanoi 2015, pp.112-123 Truong Thi Dieu Minh Research on clinical characteristics and some prognostic factors in patients with tetanus (2011 - 2016) Master of Medicine thesis Military Medical University 2016 Nguyen Van Nhung Study of some epidemiological, clinical and laboratorical characteristics and prognostic factors for tetanus patients treated at National Hospital of Tropical Diseases (from January 2010 to July 2011) Master of Medicine thesis Military Medical University 2011 Nguyen Thi Tam Epidemiological, clinical and laboratory characteristics and prognostic factors of tetanus-treated patients at 103 Hospital and 108 Central Military Hospital from 1994 - 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Thi Tam Epidemiological, clinical and laboratory characteristics and prognostic factors of tetanus- treated patients at 103 Hospital and 108 Central Military Hospital from 1994 - 2003 Master of. .. Pilaca A, Beqiri A, Ndreu A. H et al Factors affecting the prognosis of Albanian adult patients with generalized tetanus G Chir 2012, 33 (4), pp.105-109 Ramachandra L Shobha K.L A retrospective clinical. .. was 1.5/1) [2] and Nguyen Thi Tam observed male patients had higher threefold ages than female patients Severe prognostic factors in tetanus patients Patients with age > 60 years had higher fatality