Infectious Disease

Tetanus

Tetanus is a rare but life-threatening neurological disease caused by tetanospasmin from Clostridium tetani in a wound; recognise it clinically, give urgent hospital treatment and post-exposure prophylaxis according to the current UKHSA wound algorithm, and prevent it with the five-dose vaccine schedule.

In a nutshell

Tetanus is a rare but life-threatening clinical syndrome caused by tetanospasmin from Clostridium tetani in a contaminated or unnoticed wound. Trismus, risus sardonicus, rigidity and stimulus-triggered spasms may progress to airway failure and autonomic instability. Treat immediately in hospital with wound debridement, weight-based IVIG, an anaerobic antimicrobial, spasm and critical-care support, then vaccinate. For wounds, use the current UKHSA algorithm based on wound category and documented vaccine history; do not rely on antibody testing to rule out disease.

Classic presentation

An incompletely immunised person develops lockjaw and painful stimulus-triggered spasms after a deep soil-contaminated puncture wound, with a clear sensorium and possible autonomic instability.

Key points

Tetanospasmin blocks inhibitory glycine and GABA release, producing trismus, rigidity and spasms.
Tetanus is a clinical diagnosis; do not wait for wound PCR, culture or antibody results before treatment.
Treat suspected disease urgently with wound debridement, IVIG, anaerobic antimicrobial therapy, benzodiazepine-based spasm control and critical care.
Current UK guidance recommends IVIG for clinical tetanus because IV tetanus-specific immunoglobulin is no longer available; check current weight-based product guidance.
For a tetanus-prone wound, use documented vaccination history and the clean/tetanus-prone/high-risk wound algorithm; a full UK schedule is five doses.
Tetanus does not reliably confer immunity, so vaccinate after recovery and notify suspected cases in England.

First-line investigation

Clinical diagnosis with airway, autonomic and wound assessment, debrided tissue for reference-laboratory PCR/culture where possible, and documented immunisation history; no test should delay treatment.

Management

Recognise and stabilise clinical tetanus

Treat trismus, rigidity or stimulus-triggered spasms after a compatible wound as a medical emergency and admit without waiting for laboratory confirmation.^1,3
Use quiet low-stimulation nursing, early airway and critical-care planning, benzodiazepine-based spasm control and management of autonomic instability.^1,5

Neutralise toxin and remove the source

Give current weight-based IVIG early, thoroughly clean and debride devitalised wound tissue, and send samples for reference-laboratory PCR/culture where possible.^2,1,8
Give an anaerobic antimicrobial such as IV benzylpenicillin or metronidazole according to local microbiology advice and current BNF.^1,5

Prevent tetanus after a wound

Classify the wound and check documented vaccination history; for incomplete or uncertain vaccination, a tetanus-prone wound needs vaccine and a high-risk wound may also need IM-TIG or HNIG in a different site.^2,6
Remember that the full UK schedule is five doses, while at least three doses is the threshold used in the wound-risk algorithm; do not use point-of-care antibody testing as a substitute for records.^2,1,3

Support airway and organ complications

Anticipate laryngospasm, aspiration, respiratory failure, fractures, rhabdomyolysis, arrhythmia and autonomic instability; involve anaesthesia and intensive care early.^1,3,5
Notify suspected tetanus to the local health protection team in England without waiting for laboratory confirmation.^1,4

Complete immunisation and prevent recurrence

Tetanus illness does not reliably confer immunity, so complete the five-dose tetanus-containing schedule after recovery using the current UK schedule and records.^2,3
Teach wound protection and prompt review of deep, dirty, puncture, bite, burn or devitalised injuries when vaccination is incomplete or uncertain.^6,1,3

Exam traps

A negative wound culture or PCR does not exclude tetanus.
Protective serum antibody levels do not rule out clinical tetanus, and point-of-care antibody testing is not recommended for the wound algorithm.
IM-TIG is for selected wound prophylaxis; clinical tetanus needs weight-based IVIG under current UKHSA guidance.
Tetanus is not spread person to person and there is no herd-immunity protection for an unvaccinated individual.
Recovery from tetanus does not reliably produce immunity; complete the vaccine course after recovery.
A booster rule cannot be used without classifying the wound and checking the documented primary course.

Illustrations

Opisthotonus in generalised tetanusA clinical photograph of generalised tetanus showing severe extensor spasm with the trunk and limbs held in opisthotonus.CDC, Wikimedia Commons · Public domain

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.