Highlights & Basics
- Tetanus is an acute infection caused by the bacterium Clostridium tetani. Tetanus spores are highly prevalent in soil and manure and may be introduced into the body via broken skin (e.g., a puncture wound, burn, or scratch).
- Prevention of tetanus includes appropriate management of tetanus-prone wounds and complete active immunization, with passive immunization administered when required.
- Diagnosis is based on clinical findings that include trismus, muscle rigidity, spasms, respiratory embarrassment, dysphagia, or autonomic dysfunction.
- Management of clinical tetanus includes supportive care, wound debridement, antimicrobials, passive and active immunization, control of muscle spasms, and management of autonomic dysfunction.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
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Trismus
Trismus
Opisthotonus
Observation chart illustrating autonomic dysfunction with extreme fluctuation in blood pressure
US recommendations for tetanus wound management. DTaP = diphtheria and tetanus toxoids and acellular pertussis vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; Td = tetanus and diphtheria toxoids; TIG = tetanus immune globulin. *DTaP is recommended for children aged <7 years. Tdap is preferred to Td for persons aged ≥11 years who have not previously received Tdap. Persons aged ≥7 years who are not fully immunized against pertussis, tetanus or diphtheria should receive one dose of Tdap for wound management and as part of the catch-up series. **Immunosuppressed patients should be managed as if they were incompletely immunized (i.e., those with contaminated wounds should also receive TIG, regardless of their history of tetanus immunization)
Tetanus severity score. The final score is calculated from the sum of the scores for each section. A total of ≥8 indicates predicted death; <8 indicates predicted survival
Citations
UK Health Security Agency. Tetanus: the green book, chapter 30. Jun 2022 [internet publication].[Full Text]
Centers for Disease Control and Prevention. Child and adolescent immunization schedule by age: recommendations for ages 18 years or younger, United States, 2025. Nov 2024 [internet publication].[Full Text]
Centers for Disease Control and Prevention. Adult immunization schedule by age: recommendations for ages 19 years or older, United States, 2025. Nov 2024 [internet publication].[Full Text]
Havers FP, Moro PL, Hunter P, et al. 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 Jan 24;69(3):77-83.[Abstract][Full Text]
Tiwari TSP, Moro PL, Acosta AM. Tetanus. In: Hall E, Wodi AP, Hamborsky J, et al, eds. Centers for Disease Control and Prevention. Epidemiology and vaccine-preventable diseases. 14th ed. Washington, D.C.: Public Health Foundation; 2021.[Full Text]
1. Brook I. Current concepts in the management of Clostridium tetani infection. Expert Rev Anti Infect Ther. 2008 Jun;6(3):327-36.[Abstract]
2. Roper MH, Vandelaer JH, Gasse FL. Maternal and neonatal tetanus. Lancet. 2007 Dec 8;370(9603):1947-59.[Abstract]
3. 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 Apr 27;67(2):1-44.[Abstract][Full Text]
4. UK Health Security Agency. Tetanus: the green book, chapter 30. Jun 2022 [internet publication].[Full Text]
5. Centers for Disease Control and Prevention. About tetanus. Feb 2019 [internet publication].[Full Text]
6. Centers for Disease Control and Prevention (CDC). Tetanus surveillance: United States, 2001-2008. MMWR Morb Mortal Wkly Rep. 2011 Apr 1;60(12):365-9.[Abstract][Full Text]
7. World Health Organization. Tetanus reported cases and incidence [internet publication].[Full Text]
8. Collins S, Amirthalingam G, Beeching NJ, et al. Current epidemiology of tetanus in England, 2001-2014. Epidemiol Infect. 2016 Dec;144(16):3343-53.[Abstract]
9. Hahne SJM, White JM, Crowcroft NS, et al. Tetanus in injecting drug users, United Kingdom. Emerg Infect Dis. 2006 Apr;12(4):709-10.[Abstract][Full Text]
10. UK Health Security Agency. Shooting up: infections among people who inject drugs in the UK. Feb 2022 [internet publication].[Full Text]
11. UK Health Security Agency. Research and analysis: tetanus in England: 2022. Jun 2023 [internet publication].[Full Text]
12. Thwaites CL, Farrar JJ. Preventing and treating tetanus. BMJ. 2003 Jan 18;326(7381):117-8.[Abstract][Full Text]
13. Kyu HH, Mumford JE, Stanaway JD, et al. Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015. BMC Public Health. 2017 Feb 8;17(1):179.[Abstract][Full Text]
14. World Health Organization. Maternal and neonatal tetanus elimination [internet publication].[Full Text]
15. Vandelaer J, Birmingham M, Gasse F, et al. Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative. Vaccine. 2003 Jul 28;21(24):3442-5.[Abstract]
16. Thwaites CL, Beeching NJ, Newton CR. Maternal and neonatal tetanus. Lancet. 2015 Jan 24;385(9965):362-70.[Abstract]
17. Kanu FA, Yusuf N, Kassogue M, et al. Progress toward achieving and sustaining maternal and neonatal tetanus elimination - worldwide, 2000-2020. MMWR Morb Mortal Wkly Rep. 2022 Mar 18;71(11):406-11.[Abstract][Full Text]
18. Kaur G, Danovaro-Holliday MC, Mwinnyaa G, et al. Routine vaccination coverage - worldwide, 2022. MMWR Morb Mortal Wkly Rep. 2023 Oct 27;72(43):1155-61.[Abstract][Full Text]
19. Farrar JJ, Yen LM, Cook T, et al. Tetanus. J Neurol Neurosurg Psychiatry. 2000 Sep;69(3):292-301.[Abstract][Full Text]
20. Schiavo G, Benfenati F, Poulain B, et al. Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin. Nature. 1992 Oct 29;359(6398):832-5.[Abstract]
21. Reid PM, Brown D, Coni N, et al. Tetanus immunisation in the elderly population. J Accid Emerg Med. 1996 May;13(3):184-5.[Abstract][Full Text]
22. Fauveau V, Mamdani M, Steinglass R, et al. Maternal tetanus: magnitude, epidemiology and potential control measures. Int J Gynaecol Obstet. 1993 Jan;40(1):3-12.[Abstract]
23. Public Health England. Advice on tetanus for people who inject drugs. May 2013 [internet publication].[Full Text]
24. Yen LM, Dao LM, Day NP, et al. Role of quinine in the high mortality of intramuscular injection tetanus. Lancet. 1994 Sep 17;344(8925):786-7.[Abstract]
25. Udwadia FE. Tetanus. New York, NY: Oxford University Press; 1994.
26. World Health Organization. Tetanus vaccines: WHO position paper - February 2017. Wkly Epidemiol Rec. 2017 Feb 10;92(6):53-76.[Abstract][Full Text]
27. Centers for Disease Control and Prevention. Child and adolescent immunization schedule by age: recommendations for ages 18 years or younger, United States, 2025. Nov 2024 [internet publication].[Full Text]
28. Centers for Disease Control and Prevention. Adult immunization schedule by age: recommendations for ages 19 years or older, United States, 2025. Nov 2024 [internet publication].[Full Text]
29. Havers FP, Moro PL, Hunter P, et al. 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 Jan 24;69(3):77-83.[Abstract][Full Text]
30. Oliver SE, Moore KL. Licensure of a diphtheria and tetanus toxoids and acellular pertussis, inactivated poliovirus, Haemophilus influenzae type b conjugate, and hepatitis B vaccine, and guidance for use in infants. MMWR Morb Mortal Wkly Rep. 2020 Feb 7;69(5):136-9.[Abstract][Full Text]
31. European Centre for Disease Prevention and Control. Vaccine scheduler: tetanus - recommended vaccinations. 2024 [internet publication].[Full Text]
32. Slifka AM, Park B, Gao L, et al. Incidence of tetanus and diphtheria in relation to adult vaccination schedules. Clin Infect Dis. 2021 Jan 27;72(2):285-92.[Abstract][Full Text]
33. Centers for Disease Control and Prevention. CDC Yellow Book 2024: health information for international travel. Section 5: travel-associated infections and diseases - tetanus. May 2023 [internet publication].[Full Text]
34. Blencowe H, Lawn J, Vandelaer J, et al. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int J Epidemiol. 2010 Apr;39(Suppl 1):i102-9.[Abstract][Full Text]
35. Committee on Obstetric Practice, Immunization and Emerging Infections Expert Work Group. Committee Opinion No. 718: Update on immunization and pregnancy: tetanus, diphtheria, and pertussis vaccination. Obstet Gynecol. 2017 Sep;130(3):e153-7.[Abstract][Full Text]
36. Blencowe H, Cousens S, Mullany LC, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health. 2011 Apr 13;11(Suppl 3):S11.[Abstract][Full Text]
37. Demicheli V, Barale A, Rivetti A. Vaccines for women for preventing neonatal tetanus. Cochrane Database Syst Rev. 2015 Jul 6;2015(7):CD002959.[Abstract][Full Text]
38. Tiwari TSP, Moro PL, Acosta AM. Tetanus. In: Hall E, Wodi AP, Hamborsky J, et al, eds. Centers for Disease Control and Prevention. Epidemiology and vaccine-preventable diseases. 14th ed. Washington, D.C.: Public Health Foundation; 2021.[Full Text]
39. UK Health Security Agency. Tetanus: advice for health professionals. Mar 2024 [internet publication].[Full Text]
40. Schon F, O'Dowd L, White J, et al. Tetanus: delay in diagnosis in England and Wales. J Neurol Neurosurg Psychiatry. 1994 Aug;57(8):1006-7.[Abstract][Full Text]
41. Crone NE, Reder AT. Severe tetanus in immunized patients with high anti-tetanus titers. Neurology. 1992 Apr;42(4):761-4.[Abstract]
42. Idoko JA, Amiobonomo AE, Anjorin FI, et al. Cerebrospinal fluid changes in tetanus: raised proteins and immunoglobulins in patients with severe disease. Trans R Soc Trop Med Hyg. 1990 Jul-Aug;84(4):593-4.[Abstract]
43. Rushdy AA, White JM, Ramsay ME, et al. Tetanus in England and Wales, 1984-2000. Epidemiol Infect. 2003 Feb;130(1):71-7.[Abstract]
44. Wood D, Webster E, Martinez D, et al. Case report: survival after deliberate strychnine self-poisoning, with toxicokinetic data. Crit Care. 2002 Oct;6(5):456-9.[Abstract][Full Text]
45. Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: an evidence-based review. Crit Care. 2014 Mar 26;18(2):217.[Abstract][Full Text]
46. Yen LM, Thwaites CL. Tetanus. Lancet. 2019 Apr 20;393(10181):1657-68.[Abstract]
47. Ablett JJL. Analysis and main experiences in 82 patients treated in the Leeds Tetanus Unit. In: Ellis M, ed. Symposium on tetanus in Great Britain. Boston Spa, UK: National Lending Library; 1967.
48. Brook I. Tetanus in children. Pediatr Emerg Care. 2004 Jan;20(1):48-51.[Abstract]
49. Nakajima M, Aso S, Matsui H, et al. Clinical features and outcomes of tetanus: Analysis using a National Inpatient Database in Japan. J Crit Care. 2018 Apr;44:388-91.[Abstract]
50. Campbell JI, Lam TM, Huynh TL, et al. Microbiologic characterization and antimicrobial susceptibility of Clostridium tetani isolated from wounds of patients with clinically diagnosed tetanus. Am J Trop Med Hyg. 2009 May;80(5):827-31.[Abstract][Full Text]
51. Ahmadsyah I, Salim A. Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole. Br Med J (Clin Res Ed). 1985 Sep 7;291(6496):648-50.[Abstract][Full Text]
52. Yen LM, Dao LM, Day NPJ, et al. Management of tetanus: a comparison of penicillin and metronidazole. Paper presented at: Symposium of antimicrobial resistance in southern Viet Nam; 1997; Ho Chi Minh City, Vietnam.
53. Kapoor W, Carey P, Karpf M. Induction of lactic acidosis with intravenous diazepam in a patient with tetanus. Arch Intern Med. 1981 Jun;141(7):944-5.[Abstract]
54. Attygalle D, Rodrigo N. New trends in the management of tetanus. Expert Rev Anti Infect Ther. 2004 Feb;2(1):73-84.[Abstract]
55. Gyasi HK, Fahr J, Kurian E, et al. Midazolam for prolonged intravenous sedation in patients with tetanus. Middle East J Anesthesiol. 1993 Jun;12(2):135-41.[Abstract]
56. Okoromah CN, Lesi FE. Diazepam for treating tetanus. Cochrane Database Syst Rev. 2004 Jan 26;(1):CD003954.[Abstract]
57. Buchanan N, Cane RD, Wolfson G, et al. Autonomic dysfunction in tetanus: the effects of a variety of therapeutic agents, with special reference to morphine. Intensive Care Med. 1979 May;5(2):65-8.[Abstract]
58. Engrand N, Vilain G, Rouamba A, et al. Value of intrathecal baclofen in the treatment of severe tetanus in the tropical milieu. Med Trop (Mars). 2000;60(4):385-8. [In French][Abstract]
59. Saissy JM, Demaziere J, Vitris M, et al. Treatment of severe tetanus by intrathecal injections of baclofen without artificial ventilation. Intensive Care Med. 1992;18(4):241-4.[Abstract]
60. Boots RJ, Lipman J, O'Callaghan J, et al. The treatment of tetanus with intrathecal baclofen. Anaesth Intensive Care. 2000 Aug;28(4):438-42.[Abstract]
61. Dressnandt J, Konstanzer A, Weinzierl FX, et al. Intrathecal baclofen in tetanus: four cases and a review of reported cases. Intensive Care Med. 1997 Aug;23(8):896-902.[Abstract]
62. Santos ML, Mota-Miranda A, Alves-Pereira A, et al. Intrathecal baclofen for the treatment of tetanus. Clin Infect Dis. 2004 Feb 1;38(3):321-8.[Abstract][Full Text]
63. Lee C, Zhang X, Kwan WF. Electromyographic and mechanomyographic characteristics of neuromuscular block by magnesium sulphate in the pig. Br J Anaesth. 1996 Feb;76(2):278-83.[Abstract][Full Text]
64. James MFM, Manson EDM. The use of magnesium sulphate infusions in the management of very severe tetanus. Intensive Care Med. 1985;11(1):5-12.[Abstract]
65. Lipman J, James MFM, Erskine J, et al. Autonomic dysfunction in severe tetanus: magnesium sulfate as an adjunct to deep sedation. Crit Care Med. 1987 Oct;15(10):987-8.[Abstract]
66. Attygalle D, Rodrigo N. Magnesium sulphate for control of spasms in severe tetanus. Can we avoid sedation and artificial ventilation? Anaesthesia. 1997 Oct;52(10):956-62.[Abstract]
67. Thwaites CL, Yen LM, Loan HT, et al. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet. 2006 Oct 21;368(9545):1436-43.[Abstract]
68. Attygalle D, Rodrigo N. Magnesium as first line therapy in the management of tetanus: a prospective study of 40 patients. Anaesthesia. 2002 Aug;57(8):811-7.[Abstract]
69. Rodrigo C, Samarakoon L, Fernando SD, et al. A meta-analysis of magnesium for tetanus. Anaesthesia. 2012 Dec;67(12):1370-4.[Abstract]
70. Rocke DA, Wesley AG, Pather M, et al. Morphine in tetanus--the management of sympathetic nervous system overactivity. S Afr Med J. 1986 Nov 22;70(11):666-8.[Abstract]
71. Buchanan N, Smit L, Cane RD, et al. Sympathetic overactivity in tetanus: fatality associated with propranolol. Br Med J. 1978 Jul 22;2(6132):254-5.[Abstract][Full Text]
72. Dolar D. The use of continuous atropine infusion in the management of tetanus. Intensive Care Med. 1992;18(1):26-31.[Abstract]
73. Sutton DN, Tremlett MR, Woodcock TE, et al. Management of autonomic dysfunction in severe tetanus: the use of magnesium sulphate and clonidine. Intensive Care Med. 1990;16(2):75-80.[Abstract]
74. Gregorakos L, Kerezoudi E, Dimopoulos G, et al. Management of blood pressure instability in severe tetanus: the use of clonidine. Intensive Care Med. 1997 Aug;23(8):893-5.[Abstract]
75. Southorn PA, Blaise GA. Treatment of tetanus-induced autonomic nervous system dysfunction with continuous epidural blockade. Crit Care Med. 1986 Mar;14(3):251-2.[Abstract]
76. Shibuya M, Sugimoto H, Sugimoto T, et al. The use of continuous spinal anesthesia in severe tetanus with autonomic disturbance. J Trauma. 1989 Oct;29(10):1423-9.[Abstract]
77. Freshwater-Turner D, Udy A, Lipman J, et al. Autonomic dysfunction in tetanus - what lessons can be learnt with special reference to alpha-2 agonists? Anaesthesia. 2007 Oct;62(10):1066-70.[Abstract]
78. Wesley AG, Hariparsad D, Pather M, et al. Labetalol in tetanus. The treatment of sympathetic nervous system overactivity. Anaesthesia. 1983 Mar;38(3):243-9.[Abstract]
79. King WW, Cave DR. Use of esmolol to control autonomic instability of tetanus. Am J Med. 1991 Oct;91(4):425-8.[Abstract]
80. Beards SC, Lipman J, Bothma PA, et al. Esmolol in a case of severe tetanus. Adequate haemodynamic control achieved despite markedly elevated catecholamine levels. S Afr J Surg. 1994 Mar;32(1):33-5.[Abstract]
81. Hassel B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins (Basel). 2013 Jan 8;5(1):73-83.[Abstract][Full Text]
82. Van Hao N, Loan HT, Yen LM, et al. Human versus equine intramuscular antitoxin, with or without human intrathecal antitoxin, for the treatment of adults with tetanus: a 2 × 2 factorial randomised controlled trial. Lancet Glob Health. 2022 Jun;10(6):e862-72.[Abstract][Full Text]
83. Thwaites CL, Yen LM, Glover C, et al. Predicting the clinical outcome of tetanus: the tetanus severity score. Trop Med Int Health. 2006 Mar;11(3):279-87.[Abstract][Full Text]
84. Phillips LA. A classification of tetanus. Lancet. 1967 Jun 3;1(7501):1216-7.[Abstract]
85. Vakil BJ. Table ronde: propositions pour une classification internationale. In: 4th International Conference on Tetanus, vol 1. Dakar, Senegal: Fondation Merieux; 1975:3349-67.
86. Gurses N, Aydin M. Factors affecting prognosis of neonatal tetanus. Scan J Infect Dis. 1993;25(3):353-5.[Abstract]
87. Davies-Adetugbo AA, Torimiro SE, Ako-Nai KA. Prognostic factors in neonatal tetanus. Trop Med Int Health. 1998 Jan;3(1):9-13.[Abstract][Full Text]
88. Basu S, Paul DK, Ganguly S, et al. Risk factors for mortality from neonatal tetanus: 7 years experience in North Bengal, India. Ann Trop Paediatr. 2006 Sep;26(3):233-9.[Abstract]
89. Lam PK, Trieu HT, Lubis IN, et al. Prognosis of neonatal tetanus in the modern management era: an observational study in 107 Vietnamese infants. Int J Infect Dis. 2015 Apr;33:7-11.[Abstract][Full Text]
90. Loan HT, Parry J, Nga NT, et al. Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus. Trans R Soc Trop Med Hyg. 2012 Feb;106(2):90-7.[Abstract][Full Text]
91. Chalya PL, Mabula JB, Dass RM, et al. Ten-year experiences with tetanus at a tertiary hospital in northwestern Tanzania: a retrospective review of 102 cases. World J Emerg Surg. 2011 Jul 8;6:20.[Abstract][Full Text]
92. Teknetzi P, Manios S, Katsouyanopoulos V. Neonatal tetanus--long-term residual handicaps. Arch Dis Child. 1983 Jan;58(1):68-9.[Abstract][Full Text]
93. Anlar B, Yalaz K, Dizmen R. Long-term prognosis after neonatal tetanus. Dev Med Child Neurol. 1989 Feb;31(1):76-80.[Abstract]
94. Barlow JL, Mung'Ala-Odera V, Gona J, et al. Brain damage after neonatal tetanus in a rural Kenyan hospital. Trop Med Int Health. 2001 Apr;6(4):305-8.[Abstract][Full Text]
