Tetanus

• Tetanus is caused by Clostridium tetani, which is a spore-forming, Gram-negative obligate anaerobic bacteria.
• The bacteria are ubiquitous in the environment, including soil and animal feces.
• Under anaerobic conditions the bacterial spores germinate and release two toxins, tetanolysin and tetanospasmin.

Epidemiology of Tetanus:

• Since inclusion of tetanus toxoid-containing vaccines (TTCV) were included in routine childhood immunizations in 1947, cases of tetanus have decreased by 95% and related deaths have decreased by 99%.
• Since the mid-90s, there have been an average of 40 cases/year in the US.
• Between 2009 and 2023 there have been:
  • 402 cases with 37 deaths
  • 56 cases in children with 0 deaths
  • Although 8% of wounds were tetanus-prone only 28.6% received TTCV when indicated and only 2.3% received tetanus immune globulin (TIG) when indicated
• In a recent report of 4 pediatric cases of tetanus, all were unvaccinated.

Clinical presentation:

Incubation:

• Mean 8 days (range 3-21 days)
• Dependent on inoculation size and distance of the wound from the central nervous system (CNS)

4 Clinical Types:

• Generalized: >80% of cases
• Localized: muscle spasms confined around the site of inoculation
• Cephalic: trismus and CNS palsies
• Neonatal: umbilical site infection, feeding difficulty and facial spasms

  Clinical Symptoms:

• Trismus (75–98%)
• Dysphagia (83%)
• Muscle spasms
• Muscle rigidity
• Reflex spasms (70%)
• Laryngospasm and respiratory muscle spasms
• Autonomic instability (HTN, tachycardia)

 

Diagnosis:

Tetanus is a clinical diagnosis

• Consistent clinical presentation without an alternative diagnosis
• There are no cultures or serologic tests available

 

Wound Management:

• Tetanus prone wounds: dirty/contaminated, puncture, animal bites, crush injuries, burns or frostbite
• Clean minor wound;
  • Vaccinate with a TTCV if not up to date on vaccines or it has > 10 years since last TTCV.
• Tetanus prone wound:
  • If the person has not received the primary series of the tetanus diphtheria vaccine, provide TIG and TTCV.
  • If the person has received the primary vaccine series but is either not up to date or it has been > 5 years since the last TTCV, vaccinate with a TTCV.

Management of Tetanus:

• TIG 500 IU IM (bind up circulating toxin)
• Metronidazole for 7-10 days
• Wound debridement
• Airway management
• Control muscle spasms: often with benzodiazepines
• Manage dysautonomia: often with IV magnesium sulfate
• Vaccination

 

The information contained herein should not be used as a substitute for a physician’s independent judgement as to appropriate medical care and treatment.  There may be variations in treatment that are recommended based on individual facts and circumstances.

References

1. https://www.cdc.gov/tetanus/index.html
2. Hughes MM, Amin AB, Rubis AB. Tetanus Surveillance — United States, 2009–2023. MMWR Surveill Summ 2026;75(No. SS-1):1–11.
3. Campbell KL, Amin AB, Goswitz J, et al. Notes from the Field: Tetanus in Four Children — Idaho, Minnesota, Missouri, and Wisconsin, 2024. MMWR Morb Mortal Wkly Rep 2026;75:192–193.
4. Nolt D, O’Leary ST, Aucott SW. Risks of Infectious Diseases in Newborns Exposed to Alternative Perinatal Practices. Pediatrics. 2022 Feb 1;149(2):e2021055554.
5. Sudarshan R, et al. Lancet Infect Dis. 2025 Nov;25(11):e645-e657
6. Ergönül Ö, et al. Lancet. 2026 Feb 14;407(10529):716-727