Treatment of tetanus: Drugs, antibiotics and other specialist care

Successful treatment of tetanus is best carried out in the intensive care unit in collaboration with several specialists, including an anaesthetist, neurologist, infectologist or cardiologist.

The main goals of treatment are:

• interruption of toxin production
• neutralisation of unbound toxin
• control of muscle spasms
• control of dysregulation of the autonomic nervous system
• appropriately timed supportive respiratory therapy

In the last two decades, the mainstays of therapy have been heavy sedation, muscle paralysis and artificial pulmonary ventilation.

Interruption of toxin production

Treatment of injuries

Local wound care, including surgical wound cleaning, is essential. Foreign bodies should be removed from the wound. Wounds should be kept consistently moist and left open.

Dead and necrotic tissue should also be surgically removed.

Antimicrobial treatment

Antimicrobial agents are commonly given to patients with tetanus but are likely to play only a relatively minor role in its treatment. Penicillin, which is effective against most clostridia, is no longer recommended for tetanus. Penicillin, as a GABA antagonist (the main neurotransmitter in the CNS), may exacerbate convulsions.

Currently, the appropriate therapeutic option is intravenous administration of metronidazole (500 mg every 6 hours in adults or 7.5 mg/kg every 6 hours in infants).

Alternative antibiotics are clindamycin, tetracycline and vancomycin.

Neutralisation of unbound toxin

Unfortunately, administration of an antitoxin that is supposed to inactivate the toxin bound in the CNS is not beneficial. This is because tetanospasmin is irreversibly bound to tissues. Only the toxin not yet bound can be inactivated.

Neutralizing the still circulating toxin before it binds to nerve cells will prevent the toxin from spreading in the CNS and thus significantly reduce other symptoms of tetanus. Specific treatment must be initiated immediately when this infection is suspected.

Control of muscle spasms

Massive muscle spasms can cause respiratory failure, choking and lead to general exhaustion.

The provocation of muscle cramps can be reduced by placing the patient in a dark and quiet room.

Sedation and muscle relaxation can be achieved by administering diazepam and other drugs from the benzodiazepine group (lorazepam or midazolam), which are equally effective. Although these agents are able to indirectly antagonise the effect of the toxin, they do not restore the disturbed inhibitory processes in the CNS.

If convulsions cannot be sufficiently relieved, so-called neuromuscular blockers are used. Neuromuscular blockade can be achieved by curareform drugs. The most commonly used drugs are pancuronium and vecuronium.

Treatment of dysregulation of the autonomic nervous system

It is treated by suppressing the excessive catecholamine release that causes autonomic dysfunction.

The drugs used are e.g. lablol or morphine. The latter is commonly used to control autonomic dysfunction as well as to induce sedation and regulate heart rate. Other suitable drugs are e.g. atropine, clonidine and epidural bupivicaine.

Supportive and ventilatory care

A tracheostomy (an opening to allow breathing created in the throat) and transfer to the intensive care unit must be performed promptly, before any convulsions begin.

Tracheostomy should be performed within 24 hours of diagnosis in patients who are expected to develop mild to moderate tetanus.

Initially, endotracheal intubation (a tube inserted into the airway through the oral cavity) is used. With long-term mechanical ventilation, the patient should be ventilated via a tracheostomy. This also allows better suctioning of mucus and prevents laryngospasm, which increases mortality.

It also prevents aspiration of secretions and asphyxiation or allows the introduction of additional probes needed for nutrition.

The main goal of supportive therapy is to prevent these complications:

• nosocomial infections
• decubitus ulcers
• gastrointestinal bleeding
• thromboembolic events
• tracheal stenosis

Patients with severe tetanus are bedridden and ventilated for long periods of time. The average length of stay in intensive care units is approximately 33-40 days.

During this stay they are nourished and hydrated parenterally, i.e. nutrients are given directly into the veins.

Adequate nutritional support minimizes complications caused by malnutrition, maintains electrolyte balance and improves the treatment of cardiac arrhythmias.

Prevention of thromboembolism involves the administration of heparins, low molecular weight heparins or other anticoagulants. Their administration is not delayed. Recumbent patients are at high risk of blood clots and their pathway to the bloodstream of the lungs or brain.