Which antibiotic for tetanus

These are mostly people who have not been vaccinated against tetanus or who have not kept up their booster shots every 10 years. Tetanus is a medical emergency. It will need aggressive wound treatment and antibiotics. Tetanus symptoms usually emerge about 7 to 10 days after initial infection.

However, this can vary from 4 days to about 3 weeks, and may, in some cases, may take months. In general, the further the injury site is from the central nervous system , the longer the incubation period. Patients with shorter incubation times tend to have more severe symptoms.

Muscle symptoms include spasms and stiffness. Stiffness usually starts with the chewing muscles, hence the name lockjaw. Muscle spasms then spread to the neck and throat, causing difficulties with swallowing. Patients often have spasms in their facial muscles. Breathing difficulties may result from neck and chest muscle stiffness.

In some people, abdominal and limb muscles are also affected. In severe cases, the spine will arch backward as the back muscles become affected. This is more common when children experience a tetanus infection. Any cut or wound must be thoroughly cleaned to prevent infection. A tetanus-prone wound should be treated by a medical professional immediately. Any patient with a wound listed above should receive tetanus immunoglobulin TIG as soon as possible, even if they have been vaccinated.

Tetanus immunoglobulin contains antibodies that kill Clostridium tetani. It is injected into a vein and provides immediate short-term protection against tetanus. TIG is just short-term and does not replace the long-term effects of vaccination. Experts say that TIG injections can be safely administered to pregnant and breastfeeding mothers.

Doctors may prescribe penicillin or metronidazole for tetanus treatment. These antibiotics prevent the bacterium from multiplying and producing the neurotoxin that causes muscle spasms and stiffness.

If the doctor thinks the tetanus prone wound is very large, they may surgically remove as much of the damaged and infected muscle as possible debridement. Debridement is the act of removing dead or contaminated tissue, or foreign material. In the case of a tetanus-prone wound , the foreign material may be dirt or manure. A patient with tetanus requires a high daily calorie intake because of increased muscle activity.

Some patients may need ventilator support to help with breathing if their vocal cords or respiratory muscles are affected. Tetanus is caused by the Clostridium tetani bacterium. Clostridium tetani spores are able to survive for a long time outside of the body.

Bhagwanjee and colleagues [ 23 ] assessed the role of epidural blockade with bupivacaine and sufentanil in controlling the sympathetic hyperactivity in 11 patients with severe tetanus. Midazolam was used as the major sedative in all patients. There was a non-significant reduction in heart rate fluctuations as well. The observations in this regard have not been investigated by others.

Both groups received the same treatment otherwise. Blood pressure fluctuations were minimized with 3 days of clonidine administration and this group had a significantly lower mortality rate than the group not receiving clonidine. Dolar in [ 62 ] reported four patients managed with continuous atropine infusions in addition to standard therapy. The authors argue that although autonomic disturbance is widely accepted to be due to sympathetic overdrive, it may also be due to acetylcholine toxicity.

There was one death in the series due to an unrelated cause and the other three patients survived. Though blood pressure fluctuations did stabilize in two patients after atropine use, it is difficult to gauge a direct therapeutic benefit as this was not a controlled trial.

Though it did not completely abolish muscle spasms and rigidity, it managed to reduce the need for other sedatives and muscle relaxants [ 63 ]. One of the earliest drugs used to try to tackle the sympathetic overdrive in tetanus was labetolol [ 64 ]. There are several case reports of labetolol being successfully used to treat adrenergic crises in tetanus characterized by tachycardia and hypertension [ 65 , 66 ].

In one case series of 15 patients, labetolol reduced tachycardia and blood pressure, but heart rate and blood pressure variability did not improve [ 67 ]. In some instances labetolol had to be co-administered with other drugs such as clonidine for a complete response [ 68 ].

Successful use of other beta blockers such as esmolol has also been described in the literature as case reports [ 69 ]. Intravenous morphine is another option to counter autonomic hyperactivity in tetanus. In a series of ten patients, intravenous infusion of morphine successfully controlled signs of autonomic dysfunction without the need for adrenergic blockers [ 70 ].

Part of this effect may be due to the analgesic effect of morphine reducing anxiety. Other authors have also observed the efficacy of morphine in this regard and some have attempted different routes of administration, such as intrathecal administration [ 71 , 72 ]. Vitamin C has been shown to reduce mortality from tetanus in animal studies.

A single unblinded controlled trial presumably non-randomized conducted in by Jahan and colleagues [ 73 ] showed a significant reduction in mortality in adults and children receiving a daily dose of 1 g intravenous vitamin C as adjunctive therapy.

The methodological flaws in this trial and lack of confirmation of the results in other studies make it difficult to comment on this observation [ 74 ]. Administration of human antitetanus immunoglobulin HTIg or equine antitetanus serum is an established practice in the treatment of tetanus. Since the damage caused by tetanospasmin that has entered the nervous system is irreversible, much emphasis is placed on neutralizing the circulating toxin before it enters the nervous system.

Many authors have explored whether administering these immunoglobulins intrathecally rather than the traditional intramuscular injections would have an additional benefit. Sun and colleagues [ 75 ] report a non-randomized controlled unblinded trial where 9 patients out of 17 with tetanus of varying severity received IU of intrathecal HTIg as adjunctive therapy. Both groups were comparable in severity of disease, age group and other treatments received, including HTIg via the standard route to all patients.

The observed mortality rate was significantly less for the group receiving intrathecal therapy and the total duration of ICU stay and the hospital stay was also less though did not differ significantly from the control group.

The rest of the treatment protocols were similar for both groups. While there was no significant difference in mortality rates, need for mechanical ventilation or occurrence of complications, a statistically significant improvement was observed in the treatment group with regard to improvement of spasms and reduction in hospital stay. A similar observation of a shorter hospital stay plus a significant mortality benefit was made by Ahmad and colleagues [ 77 ], who conducted a non-blinded controlled trial administering intrathecal HTIg study group versus standard therapy control group for neonatal tetanus.

In a retrospective analysis of 66 patients who were administered HTIg intrathecally, Geeta and colleagues [ 78 ] concluded that complications were less compared to other centers where immunoglobulin was administered intramuscularly. While many of the studies mentioned above favor intrathecal administration of human immunoglobulin, the evidence for its benefit is not concrete. Many confounding factors might have led to a better outcome rather than the intrathecal administration of immunoglobulins itself.

Two Cochrane reviews on the subject have found conflicting results in this regard. The analysis by Abrutyn and Berlin [ 79 ] does not recommend the intrathecal use of either human immunoglobulin or equine antitetanus serum unless in the context of a randomized clinical trial.

A later metanalysis by Kabura and colleagues [ 80 ], however, concluded that intrathecal immunoglobulin or antitetanus serum administration is preferable to standard intramuscular administration. When opting for intrathecal administration of immunoglobulins, the clinician must also take into account the rare but reported adverse event of reversible paraplegia [ 81 ].

Tetanus infection does not induce immunity; therefore, active immunization is also recommended for a patient as part of treatment. The tetanus toxoid should be given at a separate site from immunoglobulin administration. Those who have not had active immunization before will need another two booster doses within 1 year of the first dose. Antibiotics are administered to patients with tetanus on the presumption that it prevents local proliferation of C.

The antibiotics that can be used include penicillin G, metronidazole and doxycycline. However, although resistance is rare, the bacteria may not be universally sensitive to the first-line antibiotics in tetanus.

An analysis of microbiological susceptibility of C. After treating with high dose penicillin, however, two isolates were found to be penicillin-resistant 16 days later [ 82 ]. While these findings cannot be applied universally due to various local resistance patterns of bacteria, it nevertheless stresses the need for repeated sensitivity testing during treatment.

While penicillin and metronidazole are both recommended in treating tetanus, some argue that metronidazole may be a better option. This is based on the fact that penicillin produces a non-competitive voltage-dependent inhibition of GABA-A receptors obtunding post-synaptic inhibitory potentials.

In this regard, penicillin in large doses is known to cause seizures and many have proposed a theoretical possibility of potentiating the action of tetanospasmin. If such an effect exists, it becomes a serious issue as there is no solid evidence for a benefit of antibiotic therapy itself in tetanus. The question remains whether, in that case, penicillin administration may do more harm than good. A trial by Ahmadsyah and Salim [ 83 ] demonstrated a mortality benefit for patients treated with metronidazole compared to penicillin as far back as Based on these data, many experts recommended metronidazole over penicillin [ 84 , 85 ].

Later, in a randomized controlled trial in India, Ganesh Kumar and colleagues [ 86 ] assessed outcome after three different antibiotic preparations were given to patients with tetanus. These were benzathine penicillin 1. While the three arms were similar in age distribution, sex and severity of tetanus score according to Ablett criteria, no significant difference in outcome was observed in relation to the duration of hospital stay, need for mechanical ventilation, need for neuromuscular blockade and concurrent respiratory tract infections.

However, given their theoretical importance of use, designing clinical trials to evaluate their efficacy against placebo is unethical. Many treatment options mentioned above have not been assessed with randomized controlled trials and it is becoming increasingly difficult to do so given the rarity of the illness. In the few developing resource-limited settings where tetanus still occurs at a high frequency, infrastructure and technical expertise to carry out clinical trials are not available.

Some expensive treatment strategies, such as intrathecal baclofen, are out of reach for researchers in such settings and may even be harmful for patients if sterility cannot be maintained in a controlled environment. The efficacy of different treatment modalities also depends on the severity of disease in each patient. For a comparison of patients between studies, there should be a uniform scoring system to assess severity of disease.

Different studies have used various measures to assess severity and others have not commented on it at all, which makes it difficult to objectively assess the therapeutic efficacy for each option. The traditional management strategy in tetanus involves sedation, neuromuscular paralysis and elective ventilation combined with wound debridement, antibiotic therapy and administration of HTIg or equine antitetanus serum to neutralize the toxin.

Due to the associated complications of prolonged ventilation, many have searched for ways of reducing the need for paralysis and elective ventilation. The evidence base for these practices is as follows a detailed summary of these recommendations is given in Table 1. Level of evidence: A, data derived from multiple randomized clinical trials or meta-analysis; B, data derived from a single randomized trial or non-randomized trials; C, only consensus opinion of experts, case studies or standard of care.

Despite benzodiazepines being popular as standard therapy for sedation and reducing spasms, the evidence for their superiority over other options is lacking. However, this may be due to the difficulty and ethical issues in designing trials to evaluate their efficacy. Intravenous magnesium sulfate reduces muscle spasms and autonomic dysfunction but it may not be suitable as sole therapy to relieve spasms in severe tetanus and has no proven mortality benefit.

Intrathecal baclofen is an effective option to relieve spasms till recovery but its use is limited due to costs and the risks of introducing concurrent central nervous system infection. Benefits reported with dantrolene, botulinum toxin for local forms of spasms in reducing muscle spasms and that of epidural blockade and clonidine to reduce autonomic dysfunction need to be further evaluated with controlled trials before being recommended as standard therapy.

The beneficial role of intrathecal HTIg or equine antitetanus sera is not well established. However, the majority of studies are in favor of intrathecal administration. Recommendations cannot be made for the exact dose for intrathecal administration. The evidence base for the efficacy of antibiotics in tetanus is limited.

Metronidazole and penicillin can be used as the bacterium is susceptible to both. There is a theoretical advantage of using metronidazole but its clinical correlations have not been well established by trials. All authors have participated in designing, article search, information coding and writing of the manuscript. All authors have read and approved the final manuscript. National Center for Biotechnology Information , U. Journal List Crit Care v. Crit Care. Published online Mar Author information Copyright and License information Disclaimer.

Corresponding author. Chaturaka Rodrigo: moc. This article has been cited by other articles in PMC. Abstract Tetanus is becoming rarer in both industrialized and developing nations due to an effective vaccination program. Introduction Tetanus is caused by the obligatory anaerobic Gram-positive bacillus Clostridium tetani. Benzodiazepines Benzodiazepines are the standard therapy for controlling muscle spasms in tetanus and have gained popularity over other agents due to their combined muscle relaxant, anticonvulsant, sedative and anxiolytic effects, which can be quite useful in managing a patient with tetanus.

Intravenous magnesium sulfate Magnesium sulfate is a widely accepted therapy for controlling eclampsia in obstetric practice. Other measures used for sedation and control of autonomic dysfunction Dantrolene is a muscle relaxant that is effectively used in the treatment of malignant hyperthermia and neuroleptic malignant syndrome.

Neutralization of toxin: route of administration of immunoglobulins Administration of human antitetanus immunoglobulin HTIg or equine antitetanus serum is an established practice in the treatment of tetanus. Antibiotics in tetanus Antibiotics are administered to patients with tetanus on the presumption that it prevents local proliferation of C. Conclusions The traditional management strategy in tetanus involves sedation, neuromuscular paralysis and elective ventilation combined with wound debridement, antibiotic therapy and administration of HTIg or equine antitetanus serum to neutralize the toxin.

Table 1 Summary of evidence base for treatment modalities used in tetanus. The sedative effect of morphine reduces anxiety and cardiovascular instability Evidence limited to case reports and few case series level of evidence C Use may be reasonable on a case by case basis Disadvantages: beta blockers can worsen hypotension, bradycardia Administration of immunoglobulins Administration of immunoglobulins is beneficial. The best route of administration intramuscular alone versus intrathecal plus intramuscular is debated Evidence from two meta-analyses are conflicting Intrathecal administration of immunoglobulins in addition to intramuscular administration may be beneficial Use of antibiotics Metronidazole use has a theoretical advantage over penicillin use as the latter can potentially facilitate tetanospasmin activity There are no trials to suggest that antibiotic use is beneficial in tetanus Either penicillin or metronidazole may be used as the antibiotic of choice in treating tetanus expert opinion Evidence from a randomized controlled trial shows no benefit of choosing metronidazole over penicillin level of evidence B.

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Acta Anaesthesiol Scand. Seizures may occur, and the autonomic nervous system may also be affected. In most settings, a disaster does not increase the risk for tetanus. This includes earthquakes, hurricanes, floods, and tsunamis. However, you can minimize the risk of tetanus among your patients who are disaster survivors and emergency responders by following routine vaccination recommendations and providing proper wound care.

Most reported cases occur in adults. In addition, a quarter of those reported cases were among people 65 years old or older. The risk of death from tetanus is highest among people 65 years old or older. Diabetes, a history of immunosuppression, and intravenous drug use may be risk factors for tetanus. In most settings, a disaster e. Minimize the risk of tetanus among your patients who are disaster survivors and emergency responders by following routine vaccination recommendations and providing proper wound care.

Tetanus is a clinical syndrome without confirmatory laboratory tests. Characteristic symptoms of tetanus are painful muscular contractions, primarily of the masseter and neck muscles and secondarily of trunk muscles. Trismus, or lockjaw, is a common sign of tetanus see generalized tetanus under Clinical Features. A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, although rigidity is sometimes confined to the region of injury.

Generalized spasms occur, frequently induced by sensory stimuli. History of an injury or apparent portal of entry may be lacking. Clinicians rarely recover the organism from the site of infection. The incubation period ranges from 3 to 21 days, averaging about 10 days. In general, the further the injury site is from the central nervous system, the longer the incubation period. A shorter incubation period is associated with more severe disease, complications, and a higher chance of death.

In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. Nervous system abnormalities, as well as a variety of complications related to severe spasm and prolonged hospitalization, can accompany generalized tetanus. The clinical course of generalized tetanus is variable and depends on the.