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<Disease review> Tetanus 감염 내과 / R3 이민혜 1 Introduction • First described by Hippocrates • Etiology discovered in 1884 by Carle and Rattone • Passive immunization used for treatment and prophylaxis during World War I • Tetanus toxoid first widely used during World War II 2 Clostridium tetani • Anaerobic gram-positive rod, spore forming bacteria • Spores found in soil, animal feces; may persist for months to years • Multiple toxins produced with growth of bacteria • Tetanospasmin estimated human lethal dose = 2.5ng/kg 3 Pathogenesis • Anaerobic conditions allow germination of spores and production of toxins • Toxin binds in central nervous system • Interferes with neurotransmitter release to block inhibitor impulses • Leads to unopposed muscle contraction and spasm 4 Epidemiology • Reservoir : soil and intestine of animals and humans • Transmission : contaminated wounds, tissue injury • Temporal pattern : peak in summer or wet season • Communicability : not contagious 5 Epidemiology 6 Secular trends in the US 7 Incidence of tetanus in Korea <파상풍 연간 발생수> 19 16 17 14 11 8 8 11 10 10 8 4 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 질병관리본부 http://www.cdc.go.kr 8 Clinical features • Incubation period; 8days (range, 3-21days) • Three clinical forms Local (not common) Cephalic (rare) Generalized (most common) • Generalized tetanus : descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms • Spasms continue for 3-4 weeks; complete recovery may take months 9 Complications • Laryngospasm • Fractures • Hypertension • Nosocomial infections • Pulmonary embolism • Aspiration pneumonia • Death 10 Diagnosis • No laboratory findings characteristic of tetanus • The diagnosis is entirely clinical and does not depend upon bacteriologic confirmation • C. tetani Wound in only 30% of cases Can be isolated from patients who do not have tetanus 11 Medical management • Antimicrobial therapy : relatively minor role in the management of tetanus, universally recommended Metronidazole(500mg IV every six to eight hours) : 7 to 10 days Alternative : penicillin G(2 to 4 million units IV every four to six hours) • If tetanic spasms are occurring, supportive therapy and maintenance of an adequate airway are critical • Tetanus immune globulin (TIG) : recommended for persons with tetanus Only help remove unbound tetanus toxin It cannot affect toxin bound to nerve endings A single intramuscular dose of 3,000 to 5,000 units Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available • Active immunization with tetanus toxoid should begin or continue as 12 soon as the person’s condition has stabilized Tetanus toxoid • Formalin-inactivated tetanus toxin • Schedule 3 or 4 doses + booster Booster every 10 years • Efficacy; approximately 100% • Duration; approximately 10 years • Should be administered with diphtheria toxoid as DTaP, DT, Td, or Tdap DTaP = Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed DT = Diphtheria, Tetanus toxoids - pediatric Td = Tetanus & diphtheria toxoids - adult Tdap = Tetanus & diphtheria toxoids and acellular pertussis vaccine 13 Td vs. Tdap • Td vaccine Used for many years Protects against tetanus and diphtheria • Tdap vaccine Licensed in 2005 First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria • 11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose JDT JADTP JDTPB 14 Td vs. Tdap • Td vaccine Used for many years Protects against tetanus and diphtheria • Tdap vaccine Licensed in 2005 First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria • 11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose JDT JADTP JDTPB 15 Wound management • All wounds should be cleaned • Necrotic tissue and foreign material should be removed • Proper immunization plays the more important role 16 표준 예방접종 일정표(소아용) 17 2012년 대한감염학회 권장 성인예방접종표 18 질환(상황)에 따른 성인예방접종 권장 19 의료인에게 권장하는 예방접종 20