Introduction

● Tetanus is an infection caused by bacteria called Clostridium

tetani (C. tetani), that are found in the environment.
● Tetanus is an uncommon but very serious disease that
requires immediate treatment in a hospital.
● It is characterised by tonic muscular spasms with painful
muscle rigidity.
● Pain often begins in the jaw muscles (Trismus or ‘lockjaw’)
and neck, shoulder and abdominal muscles.
● As the disease progresses, muscle groups throughout the
body are affected and spontaneous generalised seizure-like
tetanospasms develop.
● Autonomic dysfunction, including hypertension and
tachycardia alternating with bradycardia occurs. In the
absence of ventilatory support, death is usually due to
respiratory failure.
● The disease follows the entry of the spores into sterile body
sites following injury (puncture wounds), surgical operations
(due to lapse in asepsis), unhygienic practices (septic
abortion) and unsterile injections.
● The incidence of tetanus has come down greatly due to
immunisation and infection control practices.
●
Clostridium tetani
C. tetani is the causative organism of tetanus, an infection the affecting
the CNS through the peripheral nerves. It is widely distributed in soil and
in the intestines of humans and animals. It is ubiquitous and has been
recovered from a wide variety of sources.

Morphology
It is a gram-positive,slender bacillus, generally measuring about 4-8 x 0.5
µm in size, though there may be considerable variation in length. The
spores are spherical, terminal and bulging, giving the bacillus a
characteristic ‘Drumstick’ appearance. It is non capsulated and motile
due to the presence of peritrichate flagella.
C. tetani- Drumstick appearance
on Gram stain
Serology
● Ten serological types have been recognised based on
agglutination (types I to X).

Pathogenicity
● The route of entry of [Link] is through the skin or mucosa
through a breach of continuity. The disease manifests in the
nervous system. [Link] has a little invasive power. The toxin is
locally absorbed by the motor nerve endings and transported to
the CNS intra-axonally. The toxin is specifically and avidly fixed
by gangliosides of the grey matter of the nervous tissue
[Link] produces at least two distinct toxins, which are as follows:
● A powerful neurotoxin (tetanospasmin)
● A hemolysin (tetanolysin)

The two are antigenically and pharmacologically distinct and their

production is mutually independent.

Tetanospasmin
This is the toxin responsible for tetanus. It is oxygen-stable but relatively
heat-labile, being inactivated at 65o C in five minutes. It is plasmid-coded.
Mechanism of action
● The tetanus neurotoxin, tetanospasmin, binds to the presynaptic
membrane of the neuromuscular junction.
● It is internalised and transported retroaxonally to the spinal cord.
 ● It blocks the
neurotransmitters (Glycine
and GABA) from the spinal
inhibitory interneuron,
thereby producing spastic
paralysis.
● The abolition of spinal
inhibition causes
uncontrolled spread of
impulses initiated
anywhere in CNS.
● This results in muscle
rigidity and spasms due to
the simultaneous
contraction of agonists and
**Tetanospasmin resembles strychnine in its antagonists in the absence
effect**
of reciprocal inhibition.
Tetanoslysin
● This is heat-labile, oxygen-labile hemolysin, which is antigenically
related to the oxygen-labile hemolysins of C. perfringens, C. novyi
and S. pyogenes.
● It is not relevant in the pathogenesis of tetanus.

Resistance
● Spores can survive in soil for years.
● Though most of them are killed by boiling for 10-23 minutes, some
resist boiling for up to 3 hours. Autoclaving at 121oC for 120 min is
recommended to kill the spores.
● Disinfectants such as Iodine (1% aqueous solution) and Hydrogen
peroxide (10 volumes) kill the spores within a few hours.
Incubation period
● This is variable, ranging from two days to several weeks, but
is commonly 6-12 days

Mortality
● Untreated tetanus has a very high mortality rate, especially
with neonatal tetanus
Maternal and neonatal tetanus (MNT)
● Neonatal tetanus develops by the 8th day of life. The child
becomes irritable, refuses feeds and shows facial grimace with
stiff muscles.
● In rural India, tetanus used to be a common cause of death,
particularly in the newborn.
● However, universal immunisation of infants and expectant
mothers has reduced the incidence of maternal and neonatal
tetanus to a large extent.
● According to WHO, maternal and neonatal tetanus are the most
common life-threatening consequences of unclean deliveries
and poor umbilical cord care practices.
● Mortality rates are extremely high, especially when appropriate
Clinical features
● Trismus (Lockjaw): Stiffness of the jaw muscles, making it difficult
to open the mouth.
● Neck stiffness: Rigidity in the neck muscles.
● Dysphagia: Difficulty swallowing.
● Muscle spasms: Painful, powerful muscle contractions, often
triggered by minor stimuli.
● Opisthotonus: Severe arching of the back due to muscle spasms.
● Respiratory Complications: Difficulty breathing due to spasms of
the vocal cords or chest muscles, which can lead to respiratory
failure.
Laboratory Diagnosis
● Specimen: Necrotic tissue may be collected from the site of
injury.

● Cultural characteristics: The diagnosis of tetanus should

always be made on clinical grounds. Laboratory tests are usually
not helpful.

● Microscopy: It is unreliable; the demonstration of the typical

‘Drumstick’ bacilli in wounds in itself is not diagnostic of Tetanus.
The bacilli may be present in some wounds without tetanus
● Culture: The optimum temperature for its growth is 370C and
pH is 7.4. It grows on ordinary media. Growth is improved by
blood and serum but not by glucose. Isolation is more likely from
excised bits of tissue from the necrotic depths of wounds than
from wound swabs.

● C. tetani grows well in Robertson’s cooked meat broth with

turbidity and some gas formation. The meat is not digested, but
turns black on prolonged incubation. On blood agar, β-
hemolysis is produced due to the production of hemolysin
(Tetanolysin).
Prophylaxis, treatment and prevention
● The nature of prophylaxis depende wound and largely on the
type of the type of the wound and the immune status is not
known or has been > 5 years ago, an IM inj of tetanus toxoid is
advised immediately after a penetrating injury or laceration.
● Metronidazole 500 mg every six hours, either IV or orally
depending on the extent of infection is recommended.
● Penicillin G (1,00,000-2,00,000 IU/kg/day IV) is given in 2-4
divided doses.
● Tetracyclines, macrolides, clindamycin, cephalosporins and
chloramphenicol are also effective.
● Bacitracin or neomycin may be applied locally.
Tetanus prophylaxis in the
wounded Immune
Nature of Partially Non- immune
Immune
wound
Clean (wound toilet Toxoid x 1* Toxoid x 1 Toxoid x 3
performed within 6
hours)

Contaminated (soil Toxoid x 1* Toxoid x 1 TIG + Toxoid x 3 TIG +

or other foreign or antibiotics antibiotics
necrotic material
present)

Infected Toxoid x 1* + Toxoid x 1 TIG + Toxoid x 3 TIG +

antibiotics antibiotics antibiotics
● Human tetanus immunoglobulin (or anti-tetanus
immunoglobulin) (TIG)

10,000 IU, suitably diluted, may be given by slow IV infusion,

followed, if needed, maybe another 5,000 IU later.
● Surgical management: This aims at removing foreign bodies,
necrotic tissue and blood clots in order to remove any anaerobic
environment favourable for C. tetani.
● Supportive management: Control of spasms is done by
benzodiazepine and autonomic dysfunction by Magnesium
sulphate. Airway and respiratory control are mandatory.
● Prevention by immunisation: The most reliable method of
preventing tetanus is to induce active immunity by universal
immunisation of children with booster doses when appropriate.
● Passive immunisation:

Anti-tetanus serum (ATS) from hyperimmune horses. The

drawbacks of ATS are immune elimination and
hypersensitivity. Prior sensitisation also leads to type III
hypersensitivity reactions, which may range from mild, local
reactions to serum sickness. It is compulsory that a test for
hypersensitivity be done prior to the administration of
ATS.

Tetanus immunoglobulin (TIG): This provides passive

immunity without the risk of hypersensitivity. This is effective in
smaller doses (250 units) and has a longer half-life (3-5 weeks).
Passive immunisation is an emergency procedure to be
used only once.
● Active immunisation:

Patients recovering from tetanus should receive a full course of

active immunisation with tetanus toxoid, as an infection does
not confer subsequent immunity. The most effective method of
prophylaxis which is achieved by administering spaced injections
of the following:
- Formol toxoid, which is available as ‘plain toxoid’
- Adsorbed toxoid, which is adsorbed on aluminium hydroxide
or phosphate.

The tetanus toxoid is given alone or with the diphtheria toxoid and
the pertussis vaccine as a ‘triple vaccine’, in which the
pertussis vaccine acts as an adjuvant as well.
Vaccination Regimen (For
pregnant
Vaccine women)
When to Dose Route Site
give
TT-1 Early in 0.5 ml Intra-muscular Upper Arm
pregnancy

TT-2 4 weeks after 0.5 ml Intra-muscular Upper Arm

TT-1*

TT- Booster If received 2 0.5 ml Intra-muscular Upper Arm

TT doses in a
pregnancy
within the last
3 yrs*

** According to NIS
Vaccination Regimen ( For
children)
Vaccine When to Dose Route Site
give
DPT booster-1 16-24 months 0.5 ml Intra-muscular Antero-lateral
side of mid-
thigh

DPT Booster-2 5-6 years 0.5 ml Intra-muscular Upper Arm

TT 10 years & 16 0.5 ml Intra-muscular Upper Arm

years

** According to NIS
Thank
you