Tetanus

Disease/Disorder

Definition

Tetanus is a vaccine-preventable but potentially fatal disease caused by tetanospasmin, a neurotoxin produced by the bacteria Clostridium tetani. It is most common in developing countries, particularly sub-Saharan Africa and South Asia, where vaccine coverage is less prevalent and access to medical care is scarce. Conversely, this disease is rarely found in developed countries with widespread access to health care and vaccinations. Symptoms of tetanus include painful muscle spasms and generalized rigidity, typically beginning in the jaw and neck. The tetanus toxoid vaccination is the most effective form of prophylaxis for this disease. Immunity from the vaccine wanes with age, thus boosters are required for prevention.^1,2,3,4

Etiology

Tetanus is caused by the obligate anaerobic, gram-positive spore-forming bacillus Clostridium tetani that is found abundantly in the environment — specifically in soil, animal and human feces, and dust. The bacilli form spores in the environment that germinate into bacteria when they are exposed to injured tissue. The active bacterial cells then produce tetanospasmin, an exotoxin responsible for the symptoms of tetanus. The primary sources of infection are traumatic wounds but tetanus can also arise from burn injuries, surgical abscesses, intravenous (IV) drug use, circumcision, gangrene, or umbilical stump infections in neonates.^3,4

Epidemiology including risk factors and primary prevention

The largest risk factor for tetanus is incomplete immunization, while neonatal tetanus is primarily associated with home births and unsanitary cutting of the umbilical cord.  Tetanus is almost entirely vaccine preventable and maternal tetanus vaccination prevents neonatal tetanus by passing maternal antibodies through the placenta. Tetanus infection does NOT confer immunity, which stresses the importance of complete immunization. With age, vaccine immunity also wanes increasing the risk of tetanus infection, so vaccination and boosters are recommended for prevention. According to The United States Centers for Disease Control and Prevention (CDC), a single dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) is recommended. After that, a tetanus toxoid-containing booster should be administered every 10 years throughout life to maintain protection against tetanus in adolescents and adults.⁵ Another risk factor is IV drug use, as well as insulin-dependent diabetics. Those dependent on insulin for diabetes management are at a higher risk due to impaired immunity and increased risk of wounds.^4,6

Since the introduction of the tetanus toxoid vaccine, the incidence of tetanus has decreased worldwide. Despite this, tetanus is still a large cause of mortality in developing countries causing 56,000 deaths globally in 2015, 20,000 of which were in neonates.² Most cases occur in South Asia and sub-Saharan Africa, particularly in regions with poor vaccination coverage.² Additional risk factors include varicose ulcers, dermatosis, and necrosed tumors which serve as entry points for Clostridium tetani spores.³ Through more widespread vaccine availability, enhanced wound care, and improvement in neonatal care, the incidence of tetanus can be minimized with low-cost interventions.²

Patho-anatomy/physiology

Tetanus is caused by the tetanus exotoxin (tetanospasmin) produced by Clostridium tetani. The tetanus toxin undergoes retrograde transport in lower motor neuron axons and reaches the brainstem and spinal cord. Once in the central nervous system (CNS), the toxin is transported across synapses and is taken up by nerve endings of inhibitory GABAergic and/or glycinergic neurons that control lower motor neurons. Once the tetanus exotoxin is inside these neurons it cleaves vesicle-associated membrane protein (VAMP) and inhibits the release of GABA and glycine.  Loss of the inhibitory neurotransmission of GABA and glycine results in unchecked motor neuron activity, causing rigidity and spasms. These can manifest as trismus, dysphagia, opisthotonus, or rigidity/spasms of the respiratory muscles that may lead to serious complications such as respiratory failure.³

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Tetanus has 4 different clinical presentations: neonatal, localized, cephalic, and generalized. Generalized is the most common.

• Neonatal Tetanus: Occurs 3 to 7 days after delivery. Symptoms begin as difficulty feeding, poor suck/swallow, and excessive crying. Later, spasms can be seen.
• Localized Tetanus: Involves muscle contraction limited to the location of injury, usually in the limbs near the site of the contaminated wound. Can also progress to generalized tetanus in 1% to 2% of cases. If the initial site of injury in localized tetanus is to the face or scalp, localized tetanus can evolve into cephalic tetanus. The prognosis of localized tetanus is more favorable than generalized tetanus.^4,7,8
• Cephalic Tetanus: Usually associated with head lesions or chronic otitis media. Normally presents with cranial nerve palsy one to two days after infection. The most common cranial nerve involved is the facial nerve.⁹
• Generalized Tetanus: Most common form of disease. Presents gradually 3 to 21 days after initial infection with symptoms progressively worsening. Symptoms begin as spasms of the masseter muscle, resulting in trismus. These spasms spread from the head and neck to the trunk, lasting weeks. Classic findings include risus sardonicus which is a grimace caused by facial muscle contractions and opisthotonus, a position where the head, neck, and spine are hyperextended backwards.² Prognosis is related to incubation time with a shorter incubation period signifying more significant disease. Poorer prognosis is seen in cases with an incubation period less than 48 hours.⁴

Specific secondary or associated conditions and complications

The most common cause of tetanus-associated morbidity and mortality is respiratory compromise and death that can occur quickly from laryngospasm or diaphragmatic spasms, requiring ventilatory support.^2,4 These complications can be a result of airway obstruction, aspiration, or medications that reduce respiratory drive. Another complication includes autonomic dysregulation which can cause arrhythmias, fluctuating blood pressure, and profuse sweating.⁴ Other complications include pneumonia, rhabdomyolysis, deep vein thrombosis, and pressure ulcers, emphasizing the importance of early mobilization by the rehabilitation team.¹⁰

Essentials of Assessment

History

Assess for history of previous tetanus immunizations and history of known trauma with a contaminated object. An open wound is usually present, but this may not always be the case.^4,10,11 The incubation period can range from 1 day to months.⁴ It is helpful to know of any medications to investigate and rule out possibility of drug-induced dystonic reaction, neuroleptic malignant syndrome, and serotonin syndrome

Physical examination

Physical examination includes assessment for evidence of autonomic dysfunction (blood pressure fluctuations, diaphoresis, tachycardia). In addition, assess for fever and tachypnea. Some patients may present earlier in the course with spasms involving the cranial nerve innervated muscles (lock jaw/trismus), spasmic smile (risus sardonicus), and/or dysphagia. Generalized tetanus progresses to involve the entire body with severe hyperextension of the back, neck and limbs (opisthotonus).¹⁰ Perform a comprehensive neurologic exam with emphasis on cranial nerves, focal deficits, and tone.⁴ It is important to communicate and coordinate with the critical care team given the impact of sedative and paralytic medications on the physical examination.

Functional assessment

Functional assessment of patients includes muscle tone, passive range of motion of all limbs, and oral-motor function. Oral-motor dysfunction can result in malnutrition, aspiration, dysphonia, dysarthria, impaired lip and tongue movements, and poor gag reflex, among other conditions.^10,12

Laboratory studies

Laboratory studies for tetanus involve a broad workup including a complete blood count including white blood cell count to evaluate for infectious process, complete metabolic panel to monitor calcium (which can mimic tetanus if significantly low) and renal function, CK levels to assess for rhabdomyolysis, CRP and pre-albumin if there is development of pressure ulcers to monitor inflammation and nutritional status. A lumbar puncture may be indicated if neurologic infection, such as meningitis, is suspected.^4,10

Imaging

Imaging involves ruling out other conditions that can mimic tetanus and complications that can result from infection. For example, MRI of the brain to rule out a neuroinflammatory condition or focal CNS pathology, head/neck imaging to assess for an oropharyngeal abscess, chest xray to assess for pneumonia, and/or venous ultrasound to assess for a deep vein thrombosis.^4,10

Supplemental assessment tools

The main tools used are to classify a tetanus infection, as above, and the severity of the infection

• Ablett Classification of Severity of Tetanus^10,13
  • Mild: generalized spasticity, no respiratory distress, no spasms, +/- dysphagia
  • Moderate: significant rigidity, short spasms, moderate respiratory distress, dysphagia
  • Severe: generalized spasticity, prolonged spasms, severe respiratory distress, tachycardia
  • Very Severe: severe autonomic dysfunction

Early predictions of outcomes

A number of factors are related to worse outcomes, including high fever, generalized tetanus, and IV drug use. Cephalic and neonatal tetanus are associated with high morbidity and mortality. Shorter incubation time predicts more severe disease.⁴

Environmental

As spasms in tetanus can be triggered by minor stimuli, it is important to limit the amount of stimuli present. Minimizing noise, decreasing light intensity, and decreasing tactile sensation can help prevent increased spasms.⁴ 

Social role and social support system

Regions with greater healthcare resources have improved access to treatment and intensive care unit (ICU) level care, while areas with decreased resources may not have the immune globulin treatment and may use equine antitetanus serum instead.⁴ In resource-rich countries mortality rates have decreased from 44 percent to 15 percent due to mechanical intubation and antitoxin administration; however, in resource-poor countries the mortality rate remains high, thought to be due to limited access to intensive care ventilation.¹⁰

Professional issues

Since the introduction of the tetanus toxoid-vaccine, the incidence of tetanus declined by over 98% and in 2016 the rate was approximately 0.01 per 100,000 population. Despite this coverage, sporadic cases of tetanus continue to occur almost exclusively among unvaccinated or inadequately vaccinated individuals. Anti-vaccination ideologies have contributed to localized decline in vaccine coverage, but as of the time of this article, they have not yet resulted in a statistically significant increase in tetanus incidence nationwide. Encouraging vaccinations and maintaining high vaccine coverage is essential to prevent resurgence since individual and population immunity is the only effective preventive measure.¹⁴

Rehabilitation Management and Treatments

Available or current treatment guidelines

Treatment guidelines include giving intramuscular administration of human tetanus immune globulin once suspecting tetanus as sooner administration can decrease the severity of the disease.^4,11 Patients undergo local wound care, with cleaning and debridement of the wound.² Antibiotics (such as Penicillin and Metronidazole) are used for 7-10 days, which are thought to help prevent disease progression.^2,15 Patients are managed in an ICU setting to monitor for development of complications and commonly experience prolonged hospital stays.¹⁰ There is no known formal protocol for rehabilitation care in these patients; however, some studies have examined the role of positioning to prevent pressure injuries as well as neck cushions and gentle passive range of motion exercises to reduce contracture formation.¹⁰These patients present a challenge given the severity of spasms, rate of complications, and autonomic dysfunction.¹⁰ Full recovery of tetanus is expected to take several months.⁴ Early involvement of a physiatry team may be helpful to focus on prevention of these complications.

At different disease stages

Numerous studies have demonstrated benefits of a rehabilitation program in the ICU and there is early research showing benefit in patients with tetanus.¹⁵ One case report of an adult patient with very severe tetanus demonstrated improvement in functional independence at 80 days following swift initiation and gradual progression of a rehabilitation program focusing on positioning, cushioning to limit extensor tone, passive range of motion, seated training, and eventual ambulation.¹⁰ In one study from Brazil, focused rehabilitation on swallowing and oral-motor movements showed decreased time spent in the ICU and significant improvement in swallow and oral-motor function.¹⁶

Medication management is used to help alleviate the symptoms of tetanus. Spasms symptoms can be managed with IV or enteral benzodiazepines (e.g. diazepam, midazolam), IV magnesium sulfate, IV propofol and intramuscular botulinum toxin.^3,11 One case report demonstrated improvement with intrathecal baclofen.¹⁰ Autonomic dysfunction symptoms can be managed with IV or enteral clonidine, beta blockers (e.g. labetalol, esmolol), and morphine. Some case reports have shown benefit with IV dantrolene, IV ketamine along with IV diazepam, as well as epidural blocks with bupivacaine and sufentanil.^11,18

Coordination of care

Coordination between the critical care and rehabilitation teams is essential. Nursing staff maintain positioning protocols between therapy sessions and provide continuous monitoring, while ICU clinicians track autonomic instability to ensure safety during targeted therapies. Early mobilization, including in sedated, critically ill patients, should be emphasized. In one case, positioning and passive range-of-motion initiated within 24–48 hours facilitated progression to standing by hospital day 22.¹⁰ For patients with autonomic instability, rehabilitation plans should be individualized and titrated to the patient’s hemodynamic status.

Patient & family education

Education on vaccination and proper wound care is central to preventing tetanus.⁴ Families should also learn common spasm triggers, such as loud noises, bright lights, sudden movements or position changes, and handling/touching, so that the care environment can be modified accordingly.⁷ Clinicians should also set expectations about recovery: full recovery often requires 6–8 weeks or longer, and spasms may persist for 2–3 weeks despite appropriate treatment.¹⁴

Measurement of treatment outcomes

A case report examining the challenges of patients with tetanus in the ICU assessed functional independence using the Barthel Index, level of consciousness with the Glasgow Coma Scale and tone using the Modified Ashworth Scale. After 80 days, the Barthel Index improved by 10 points (noted to be a slight but measurable improvement); GCS remained the same; spasticity in the triceps remained stable and improved in hip adductors.¹⁰ The Hypertonia Assessment Tool (HAT) may be appropriate for characterizing rigidity in tetanus; however, there were no published studies found using it in this population.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Early rehabilitation interventions for patients admitted to the ICU with tetanus—such as passive range of motion, positioning, and gradual activity progression—can modestly improve functional independence and tone.¹⁰ For patients with severe rigidity unresponsive to conventional therapy, early consideration of advanced tone management strategies, such as intrathecal baclofen pump therapy, may prevent complications (e.g., neuroleptic malignant–like syndrome, chronic wounds, and contractures) and facilitate participation in rehabilitation.

Cutting Edge/Emerging and Unique Concepts and Practice

Emerging therapies are being trialed to help patients with tetanus infections. A case study examining plasma exchange therapy earlier in the course demonstrated improvement in respiratory function, cardiac function, strength, and muscle tone.¹⁹ Botulinum toxin injections are being examined in the role of hypertonia to assist with neck rigidity, dysphagia, and trismus. Studies have used onabotulinumtoxinA and abobotulinumtoxinA with injections involving the masseter, temporalis, biceps, brachioradialis, cricopharyngeal, sternocleidomastoid, trapezius, levator scapulae, and gastrocnemius muscles with timing ranging from 5 days to 8 weeks.³

In other applications, tetanus toxin has also shown benefit for prevention of muscle atrophy in immobilized limbs in animal models.²⁰

Gaps in the Evidence-Based Knowledge

Currently it is unclear which antibiotics provide the most benefit for tetanus infections.⁴ There are no published studies evaluating botulinum toxin injections to axial/truncal musculature in generalized tetanus; anticipated benefit is largely extrapolated from experience in dystonia and Parkinson disease.³ Future research on chemodenervation strategies where systemic agents are insufficient, including for axial rigidity, would be beneficial.

References

1. Stock I. Wundstarrkrampf und Clostridium tetani [Tetanus and Clostridium tetani–a brief review]. Med Monatsschr Pharm. 2015;38(2):57-60.
2. Rhinesmith E, Fu L. Tetanus Disease, Treatment, Management. Pediatr Rev. 2018;39(8):430-432. doi:10.1542/pir.2017-0238
3. Hassel B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins (Basel). 2013;5(1):73-83. Published 2013 Jan 8. doi:10.3390/toxins5010073
4. George EK, De Jesus O, Tobin EH, et al. Tetanus (Clostridium tetani Infection) [Updated 2024 Feb 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
5. Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices – United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83. Published 2020 Jan 24. doi:10.15585/mmwr.mm6903a5Farnworth E, Roberts A, Rangaraj A, Minhas U, Holloway S, Harding K. Tetanus in patients with chronic wounds — are we aware? Int Wound J. 2012;9(1):93-99. doi:10.1111/j.1742-481X.2011.00850.x
6. Darwitz BP, Genito CJ, Thurlow LR. Triple threat: how diabetes results in worsened bacterial infections. Infect Immun. 2024;92(9):e0050923. doi:10.1128/iai.00509-23
7. Minta A, Havers F, Tohme R. Tetanus. In: CDC Yellow Book: Health Information for International Travel 2024. Centers for Disease Control and Prevention. May 1, 2023. https://wwwnc.cdc.gov/travel/yellowbook/2024/infections/tetanus
8. Yen LM, Thwaites CL. Tetanus. Lancet. 2019;393(10181):1657-1668. doi:10.1016/S0140-6736(18)33131-3
9. Kagoya R, Iwasaki S, Chihara Y, et al. Cephalic tetanus presenting as acute vertigo with bilateral vestibulopathy. Acta Otolaryngol. 2011;131(3):334-336. doi:10.3109/00016489.2010.526144
10. Seki M, Sugiyama M, Maeda T, Kasai F. Challenges in Rehabilitation of a Tetanus Patient With Severe Complications. Cureus. 2024;16(12):e76494. Published 2024 Dec 27. doi:10.7759/cureus.76494
11. Hakim, D.D.L., Faried, A., Nurhadiya, A. et al. Infected open depressed skull fracture complicated with tetanus grade I in an unimmunized child: a rare case report with literature review. Int J Emerg Med 14, 25 (2021). https://doi.org/10.1186/s12245-021-00346-9
12. Mangilli LD, Sassi FC, Jacomo A, de Andrade CR. Evaluation of oral-motor movements and speech in patients with tetanus of a public service in Brazil. J Oral Rehabil. 2011 Aug;38(8):564-70. doi: 10.1111/j.1365-2842.2010.02185.x. Epub 2010 Dec 13. PMID: 21155998.
13. Ablett JJL. Boston Spa, UK: British Library Board; 1967. Analysis and main experiences in 82 patients treated in the Leeds Tetanus Unit; pp. 1–10
14. Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44. Published 2018 Apr 27. doi:10.15585/mmwr.rr6702a1
15. Anh NTK, Yen LM, Nguyen NT, Nhat PTH, Thuy TTD, Phong NT, Tuyen PT, Yen NH, Chambers M, Hao NV, Rollinson T, Denehy L, Thwaites CL. Feasibility of establishing a rehabilitation program in a Vietnamese intensive care unit. PLoS One. 2021 Mar 3;16(3):e0247406. doi: 10.1371/journal.pone.0247406. PMID: 33657158; PMCID: PMC7928504.
16. Mangilli LD, Sassi FC, de Medeiros GC, de Andrade CR. Rehabilitative management of swallowing and oral-motor movements in patients with tetanus of a public service in Brazil. Acta Trop. 2012 Jun;122(3):241-6. doi: 10.1016/j.actatropica.2012.02.069. Epub 2012 Mar 3. PMID: 22414569.
17. Dapul G, Patel P, Pannu T, Meythaler J. Treatment of severe tetanus with intrathecal baclofen via implantable infusion device: a case report. Neuromodulation. 2014 Dec;17(8):791-3. doi: 10.1111/ner.12191. Epub 2014 Jun 17. PMID: 24934627.
18.  Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-based review. Crit Care. 2014 Mar 26;18(2):217. doi: 10.1186/cc13797. PMID: 25029486; PMCID: PMC4057067.
19. Huang S, Han F, Zhang Q, Hu W, Gao K, Xie Y. Case report: Plasma exchange treatment in a patient with severe tetanus. Transfus Apher Sci. 2025 Feb;64(1):104038. doi: 10.1016/j.transci.2024.104038. Epub 2024 Nov 25. PMID: 39615257.
20. Matthews CC, Lovering RM, Bowen TG, Fishman PS. Tetanus toxin preserves skeletal muscle contractile force and size during limb immobilization. Muscle Nerve. 2014 Nov;50(5):759-66. doi: 10.1002/mus.24231. Epub 2014 Sep 29. PMID: 24590678.

Author Disclosure

Heakyung Kim, MD
AbbVie, Honorarium, Consulting Role; Merz, Honorarium; Pacira, Research Grant; Catalyst Education, Honorarium

Joshua Kaseff, MD
Nothing to Disclose

Noralis Rodriguez-Santiago, MS
Nothing to Disclose

Rajashree Srinivasan, MBBS
Nothing to Disclose

Annie Abraham, MD
Nothing to Disclose