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Tetanus !te-t/un-us

by Matthew E. Levison, MD

Tetanus (lockjaw) results from a toxin produced by the anaerobic bacteria Clostridium tetani. The toxin makes muscles become rigid and contract involuntarily (spasm).

  • Tetanus is rare in the United States but is common in developing countries.

  • Diagnosis is based on symptoms

  • Vaccination and wound care can prevent tetanus.

  • Treatment focuses on treating symptoms until they resolve.

Although rare in the United States, tetanus kills up to 500,000 people each year, mainly in developing countries.

Clostridium tetani is present in soil and animal feces. Tetanus bacteria may enter the body through wounds contaminated with soil or feces (especially if the wound is not adequately cleaned) and skin punctures by nonsterile needles (such as those used to inject illegal drugs or to tattoo or do body piercing). Sometimes the injury is so small that people do not even go to a doctor. Injuries that involve dead skin (such as burns, frostbite, gangrene, or crush injuries) are more likely to cause tetanus. When oxygen is absent in dead tissue, tetanus spores reproduce and produce a toxin that travels through the body and prevents nerves from sending signals to other nerves. Occasionally, tetanus results when the uterus is damaged during an induced abortion or childbirth. In developing countries, soil contamination of the stump of the umbilical cord can cause tetanus in newborns.

Vaccination during childhood plus booster doses every 10 years during adulthood can prevent tetanus. Thus, the infection occurs mainly in people who have not been vaccinated or not kept their vaccinations up to date. This situation is more common in developing countries. In the United States, tetanus is a risk for people who inject drugs. The risk is also higher for older people but usually only if they have never been vaccinated.

Symptoms

Symptoms usually begin about 5 to 10 days after the injury. Muscles contract involuntarily (spasm) and become rigid. Spasms usually begin in the jaw (causing lockjaw) and throat (making swallowing difficult), followed by the neck, shoulder, face, and then the abdomen and limbs. Back muscles contract, making the back arch. Spasms of sphincter muscles can lead to constipation and difficulty urinating. People may have a rapid heart beat, profuse sweating, and a high fever. Slight disturbances—such as noise, a draft, or the bed being jarred—can trigger painful muscle spasms throughout the body. Such spasms may interfere with breathing, sometimes so much that people turn blue. Rarely, muscle spasms may be limited to muscle groups near the wound. Such localized tetanus may persist for weeks. Even when the illness is severe, people remain fully conscious.

Worldwide, about 50% of people who have tetanus die. But in the United States, only about 10 to 15% die if the disorder is treated appropriately. People who inject drugs, the very young, and the very old are more likely to die of tetanus.

Diagnosis

A doctor suspects tetanus when certain muscles (commonly, jaw and back muscles) become rigid or spasms occur, particularly in people who have a wound. The bacteria can sometimes be grown (cultured) from a sample taken from the wound. Detecting the bacteria in cultures confirms the diagnosis, but tetanus is possible even if no bacteria are detected.

Did You Know...

  • Promptly and thoroughly cleaning dirty wounds can help prevent tetanus.

Prevention

Preventing tetanus is far better than treating tetanus. Tetanus rarely develops in people who have completed a primary series of tetanus vaccinations (three or more injections into a muscle) and had vaccinations every 10 years, as recommended. The tetanus vaccine stimulates the body to produce antibodies that neutralize the toxin. But neutralization can take weeks. In young children, the tetanus vaccine is given as part of a series that includes the diphtheria and pertussis (whooping cough) vaccines. Adults who have completed the primary series of tetanus vaccination should get tetanus boosters every 10 years.

When people are injured, they can help prevent tetanus by promptly and thoroughly cleaning wounds. People who have wounds may be given tetanus vaccine to prevent tetanus from developing. Because the vaccine takes weeks to be effective, tetanus immune globulin is sometimes given in addition. It provides antibodies that neutralize the toxin immediately.

After a Wound: Who Needs a Tetanus Shot?

Clean, Minor Wounds

Deep or Dirty Wounds*

Number of previous vaccinations

Tetanus vaccine

Tetanus immune globulin

Tetanus vaccine

Tetanus immune globulin

Uncertain or fewer than 3

Yes

No

Yes

Yes

3 or more

Yes, if it is more than 10 years since the last dose

No

Yes, if it is more than 5 years since the last dose

No

*Included are wounds contaminated with dirt, stool, or saliva, as well as puncture wounds, wounds involving loss of tissue, wounds caused by a penetrating object or crushing, burns, and frostbite.

Which form of the tetanus vaccine is used depends on the person’s age. For people 7 years old or older, tetanus and diphtheria toxoid (Td) vaccine is used. Children younger than 7 years old are given diphtheria, tetanus, and acellular pertussis vaccine (DTaP). Children who cannot be given pertussis vaccine (for example, those who have a seizure or certain other brain or nerve disorders) are given diphtheria and tetanus vaccine (DT)

If only three injections of tetanus vaccine have been received, a fourth dose should be given.

Treatment

People with tetanus are admitted to an intensive care unit. The room is kept quiet to prevent disturbances that could trigger muscle spasms. Wounds are cleaned thoroughly, and dead tissue and foreign material are removed.

Antibiotics (usually metronidazole) are given intravenously to kill the bacteria and thus stop the production of toxin. However, antibiotics have no effect on toxin that has already been produced. Tetanus immune globulin is usually given to neutralize the toxin already produced. Tetanus vaccine is given unless vaccinations are known to be up to date.

Sedatives, such as the benzodiazepine diazepam, may be given to control muscle spasms, to help relax rigid muscles, and to relieve pain and anxiety. If muscle rigidity interferes with breathing, an opening may be made in the windpipe (called tracheostomy). Sometimes mechanical ventilation is also needed. If swallowing is difficult, nutrition and fluids are given intravenously or, less often, through a tube inserted through the nose and into the stomach.

After people recover, they are given the full series of vaccinations to prevent future episodes of tetanus.

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