Clostridium tetani

Background

Toxin blocks inhibitory interneurons in the spinal cord and autonomic nervous system

Incubation period of 3 to 21 days
Followed by generalized tetanus, with tetanic spasms with even minimal external stimulus
Lockjaw, risus sardonicus, opisthotonus, abdominal rigidity, and eventually apnea

Baseline IgG serology; if positive, then they are tetanus-immune and it rules out the diagnosis
Send wound swab or tissue for culture or PCR

Supportive care
- Early intubation for airway protection
- Benzodiazepines to manage muscle spasms
  - Rarely, need to escalate to neuromuscular blockage
- May need α- or β-adrenergic blockade with labetalol to manage autonomic dysfunction
  - Avoid unopposed α effect, which can cause severe hypertension
- Increased nutritional support, given the high metabolic demands of the illness
Immunization
- Tetanus antitoxin, tetanus immune globulin (TIg), or IVIg can shorten the duration of illness. Administer as early as possible and within 24 hours.
- Vaccination with toxoid vaccine, within 24 hours, into a different limb.
Metronidazole may improve outcomes compared to penicillin
Wound care with debridement as indicated, though it does not alter the course of the disease

Postexposure prophylaxis involves either tetanus vaccination, tetanus immunoglobulin (TIg), or both

Immunization Status	Wound	Vaccine	Immunoglobulin
did not complete childhood series, or unknown	clean, minor injury	yes	no
did not complete childhood series, or unknown	all others	yes	yes
completed childhood series	clean, minor injury	only if last was given ≥10 years ago	no
completed childhood series	all others	only if last was given ≥5 years ago	no