Antibiotics in Tetanus

 Q: 47 Years old diabetic male who was involved in a motor vehicle accident (MVA) a week ago presented with generalized tonic contractions of skeletal muscles. With loud noise in ED, patient was found to trigger stiff neck, opisthotonus, risus sardonicus, clench fisting, arching the back, and flexing of arms. Which of the following antibiotics is preferred along with neutralization of the toxin and symptomatic treatment?  

A) Metronidazole 

B) Macrolides 

C) Clindamycin 

D) Vancomycin 

E) Chloramphenicol

Answer: A

A recent history of MVA in a diabetic male with generalized muscle spasms is classic of tetanus. Antibiotics play an adjuvant role in the treatment of tetanus. The mainstay of treatment is wound management (halting of the toxin), neutralization of the toxin, and symptomatic treatment with benzodiazepines. If a patient requires intubation, propofol, dexmedetomidine, atropine, and neuromuscular blockade may be required. Epidural bupivacaine is also helpful. Metronidazole and penicillin G are the two most effective treatments though the former is found to be more efficacious. 

Other antibiotics (choices B to E) have not been studied well though found to be effective in vitro. Although trimethoprim-sulfamethoxazole has been suggested as a treatment, the resistance is almost universal.

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References:

1. 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; 291:648. 

2. 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