A clinical retrospective study of prognostic factors in tetanus patients (2016 - 2017)

Nội dung text: A clinical retrospective study of prognostic factors in tetanus patients (2016 - 2017)

1. Journal of military parmaco-medicine n 07-2017 A CLINICAL RETROSPECTIVE STUDY OF PROGNOSTIC FACTORS IN TETANUS PATIENTS (2016 - 2017) Hoang Vu Hung*; Nguyen Lan Phuong*; Dinh Thi Phuong Lien* Han Minh Thuy**; Hoang Thi Thanh**; Luu Thi Nhan** SUMMARY Objectives: To determine various prognostic factors in tetanus patients during the period 2016 - 2017. Subjects: 64 patients were diagnosed tetanus, ages over 17, treated in the Department of Infectious Diseases at 103 Hospital and National Hospital of Tropical Diseases from June, 2016 to April, 2017. Method: The cross-sectional retrospective, descriptive study. Results: A total of the 64 patients with diagnosis of tetanus, had 53 male (70.31%) and 15 female (29.69%). The mean age was 58.7 ± 15.7 years (range 18 - 94). The outcomes of treatment were divided into two groups: 7 patients with dead, severe disease and 57 survivors. There was a significant difference between two groups in patients with dead and more severe disease and cured patients observed in relation to more severe prognostic factors were the incubation period < 14 days and period of onset within 24 hours, site of infection, the number of convulsion over 10 seizures, frequency of pulse with p< 0.05. Conclusions: In this study, we determined severe prognostic factors of tetanus disease included the time of onset within 24 hours; level of lockjaw lesser 1 cm; over 10 convulsions within 24 hours; increase of sputum and sweat; frequency of pulse over 110 cycles per minute. * Keywords: Tetanus; Prognostic factors; 2016 - 2017. INTRODUCTION disease gave a consensus including six important prognostic factors: the period of Tetanus is a severe infectious disease incubation and the time of onset, the caused by the exotoxin produced by presence of muscle spasms, the port of Clostridium tetani . The widespread use of entry, the level of fever, the frequency of tetanus vaccine in prophylaxis programs pulse [7]. has led significantly decline in incidence, However, diagnosis of tetanus is main but tetanus disease remains to be an clinical, whereas treatment is the best done, important public health problem associated prognostic factors are showed above does with high mortality all over the world, still not reflect all the follow-up process of especially in developing countries [6, 8]. diseases. So, it is very necessary to Therefore, it is very crucial to identify determine more sufficient factors for valuable prognostic factors of tetanus to predicting tetanus disease. Vietnam is a reduce the mortality rate. In 1975, Darka- developing country with tropical climate, Senegal, International Conference on tetanus located in region of countries with high * 103 Military Hospital ** Vietnam Military Medical University Corresponding author: Hoang Vu Hung (dr.hoangvuhung@yahoo.com) Date received: 10/06/2017 Date accepted: 07/08/2017 132
2. Journal of military phrmaco-medicine n O7-2017 prevalence of tetanus. Even though there Patients were divided into two groups were the Expanded Immunization Program according to the outcomes of treatment: and the advance of the treatment methods 57 survivors and 7 non-survivors: that helpe to minimize significantly the * Inclusion criteria [1]: mortality rate of patients with diagnosis of - Patients had suspicious wound with tetanus, the treatment and prognosis of the point of entry. tetanus are still a great issue to be elucidated. Because of the prolonged - Clinical symptoms at onset of the hospital stay, the high cost of treatment, first trismus, then skeletal muscles spasm and confronted complications or even death, of the head, neck, and trunk. tetanus remains major health problem and - Patients had percusive seizure with challenging. increased muscular tone. There were many tetanus patients Clinical data were recorded and data admitted in the Department of Infectious sheet was used to collect the following Diseases at 103 Hospital and National data: age, gender, address, occupation, Hospital of Tropical Diseases. From 2004 - risk factor, type and duration of 2009, Department of Infectious Diseases presenting first symptoms, duration of at 103 Hospital treated 36 patients with hospital stay, physical signs, laboratory diagnosis of tetanus, the morality rate was parameters, complication(s), mode of observed 27.8% [5]. In recent years, both treatment, outcomes at hospital two hospitals continues enrolled a lot of discharge and causes of death, time tetanus cases; but it is still lack of the period of incubation (time from injury to comprehensive research reported to access the appearance of the first symptoms) about the clinical features, severe prognostic and period of onset (interval between the factors of diseases. Therefore, this study first symptoms and the first spasm), the is to: Point out severe prognostic factors of number of eclampsia and pulse frequency patients with tetanus during 2016 - 2017. were determined. Data were analyzed and compared SUBJECTS AND METHODS between patients in group 1 and group 2 A total of the 64 patients aged > 17 years using SPSS 13.0. Chi-square test used with diagnosis of tetanus, who admitted to for categorical variables or Fisher’s exact the Department of Infectious Diseases of tests as appropriate and student’s t-tests 103 Hospital and National Hospital of and Mann - Whitney U test for quantitative Tropical Diseases between June, 2016 variables. Logistic regression was used to and April, 2017 enrolled in this cross- determine prognostic factors affecting deaths sectional descriptive study. The study from tetanus disease. To find some significant protocol was reviewed and approved by prognostic factors of tetanus, p values the institutional review board of 103 Hospital < 0.05 were considered as statistical and National Hospital of Tropical Diseases. significance. 133
3. Journal of military parmaco-medicine n 07-2017 RESULTS AND DISCUSSION 1. General characteristics of patients. Among 64 patients with tetanus, there were 45 male (70.31%) and 19 female (29.69%). The mean age was 58.7 ± 15.7 years (range 18 - 94), patients with the highest age was 94 years, whereas, the lowest age was 21 years. Our data were comparable with studies reported by Truong Thi Dieu Minh (male/female ratio was 1.5/1) [2] and Nguyen Thi Tam observed male patients had higher threefold ages than female patients. 2. Severe prognostic factors in tetanus patients. Patients with age > 60 years had higher fatality rate as compared with those under age > 60 years (85.71% vs. 33.33%). However, this difference was not statistically significant with p > 0.05. We did not observe any differences between the two groups in relation to age group above. These results were different from that of Hoang Tien Tuyen et al suggested that tetanus patients had closed wounds, ligaments, bruised, combined infection as a major prognostic factor in the outcome of tetanus treatment [5]. This difference could be explained that it was associated with size of samples, patient characteristics and the time point at the beginning of the study. The study observed most patients had the port of entry in soft tissue wound. There was a statistically significant relationship with respect to the entry sites and outcomes of treatment. Table 1: Association between age group and port of entry with treatment outcome. Treatment Dead, severe disease Survivors p Outcome n % n % Aged group 6 85.71 19 33.33 ≥ 60 > 0.05 < 60 1 14.29 38 66.67 Entry sites 4 57.14 29 50.88 Soft tissue wound > 0.05 3 42.86 23 40.35 Non-soft tissue wound Unknown 0 0 5 8.77 The most common site of infection was lower limbs (37 of 64 patients), and head, body, upper limbs (22 of 64 patients), while 5 patients were not identified site of injury. Most patients with infection in lower limbs, head, body, upper limbs had higher cured rate compared deceased or severed patients. However, there was a significant difference between two groups associated with infection sites observed. In this study, 52 of 64 patients had received SAT injection after injury and among 12 patients had not been used SAT injection after trauma, 7 patients died and more severe form of tetanus. We had showed that a significant difference between died and survived patient groups in relation to SAT use status after injury. 134
4. Journal of military phrmaco-medicine n O7-2017 Table 2: Relationship between sites of infection and the SAT injection status after injury with the outcome of treatment. Treatment results Dead, severe disease Survivors p Number % Number % Site of infection Lower limbs 4 57.14 33 57.89 > 0.05 Head, body, upper limbs 3 42.86 19 33.33 Unknown 0 0 5 8.78 Injection SAT vaccination Yes 0 100 52 91.23 < 0.05 No 7 0 5 8.77 100% of patients died and more severe disease had the period of incubation ≤ 14 days while patients cured had the period of incubation > 14 days. There was a significant difference between the two groups observed. Some authors found that patients with an incubation period of less than 14 days was prognostic factors of mortality [3, 7]. In this study, 13 of 64 patients had a period of onset less 24 hours, whereas 51 patients with period of onset more than 24 hours prior to hospital admission. The study results demonstrated a significant difference between two groups associated with the period of onset before and after 24 hours. This result indicated a short period of onset less 24 hours was a predictor of disease. Table 3: Relationship between incubation time and onset time with the outcome of treatment. Treatment results Dead, severe disease Survivors p Number % Number % Incubation period (days) ≤ 14 7 100 40 70.18 >14 0 0 12 21.05 > 0.05 Unknown 0 0 5 8.77 Onset period (hours) ≤ 24 4 57.14 9 15.79 < 0.05 > 24 3 42.86 48 84.21 Table 4: Relationship between level of trismus and number of convulsion/24 hours with treatment results . Treatment results Dead, severe disease Survivors p Number % Number % Level of trismus ≤ 1 cm 5 71.43 19 33.33 < 0.05 > 1 cm 2 28.57 38 66.67 Number of convulsion ≤ 10 0 0 48 84.21 < 0.05 10 - 100 6 85.71 9 15.79 > 100 1 14.29 0 0 135
5. Journal of military parmaco-medicine n 07-2017 In this study, we observed a significant and access the level of trismus had shown association between two groups of patients to be a prognostic significance. Patients died had a maximal trismus ≤ 1 cm, with with stronger lockjaw had the higher the those cured (p < 0.05). In addition, there mortality or more severe disease. was a statistically significant between the 100% of patients died, and more severe two groups in relation to the number of illness, had the number of seizures within convulsion observed. As compared with 24 hours were more than 10 seizures, studies reported by Nguyen Thi Tam, whereas cured group was lesser than 10 Nguyen Van Nhung indicated that tetanus seizures within 24 hours. The difference patients with maximum less than 1 cm between the two groups was statistically had the highest mortality, the patients with significant with p < 0.05, indicated that the trismus more than 2 cm had no mortality number of seizures within 24 hours was a [3, 4]. Thus, at the onset period, monitoring severe prognostic factor of tetanus disease. Table 5: Relationship between increased sputum, sweating with the outcome of treatment. Treatment results Dead, severe disease Survivors p Increase sputum, sweating Number % Number % Yes 7 100 38 66.67 > 0.05 No 0 0 19 33.33 < 0.05 100% of patients died and more severe disease had autonomic disregulation leading to increased sputum and perspiration, while cured group was 66.67%. The difference between the two groups was statistically significant (p < 0.05). This data are also comparable with the results of Truong Thi Dieu Minh's study, patients with mortality rate had increased sputum and sweat were significantly higher than the control group (91.2% vs. 22.4%, p < 0.05) [2]. Table 6: Relationship between temperature and pulse frequencies at full-blast time with the outcome of treatment. Treatment results Dead, severe disease Survivors p Number % Number % Temperature ≤ 37 0C 1 14.28 9 15.79 37 01 - 38 0C 1 14.28 17 29.82 > 0.05 38 01 - 39 0C 3 42.86 25 43.86 > 39 0C 2 28.58 6 10.53 Frequency pulses > 110 cycles/min 5 71.43 18 31.58 < 0.05 ≤ 110 cycles/min 2 28.57 39 68.42 136
6. Journal of military phrmaco-medicine n O7-2017 28.58% of patients died, severe illness REFERENCES had high fever with temperature > 39 oC, higher than the group cured (10.53%). 1. Department of Infectious Diseases - Military However, the difference between the two Medical University. Tetanus, Infectious Diseases. groups was not statistically significant with People's Army Publishing House. Hanoi. 2015, pp.112-123. p > 0.05. Truong Thi Dieu Minh's study so found that patients with body temperature 2. Truong Thi Dieu Minh. Research on clinical characteristics and some prognostic > 39 0C had a higher mortality rate, but not factors in patients with tetanus (2011 - 2016). statistically significant when compared with Master of Medicine thesis. Military Medical the group control (60% vs. 39.6%) [2]. University. 2016. 71.43% of patients with fatal, severe 3. Nguyen Van Nhung. Study of some disease, rapid pulse frequency > 110 cycles epidemiological, clinical and laboratorical per minute, while cured patients were characteristics and prognostic factors for 31.58%. The difference between two groups tetanus patients treated at National Hospital of Tropical Diseases (from January 2010 to July was a statistically significance with p < 0.05. 2011). Master of Medicine thesis. Military Medical Thus, the pulse frequency > 110 cycles/minute University. 2011. was a significant severe predictor for 4. Nguyen Thi Tam. Epidemiological, tetanus diseases. clinical and laboratory characteristics and prognostic factors of tetanus-treated patients CONCLUSION at 103 Hospital and 108 Central Military Hospital In conclusion, we studied 64 tetanus from 1994 - 2003. Master of Medicine thesis. Military Medical University. 2004. patients treated in the Department of Infectious Diseases of 103 Hospital and 5. Hoang Tien Tuyen, Trinh Thi Xuan Hoa, Do Tuan Anh. Severe prognosis in tetanus- National Hospital of Tropical Diseases treated patients at 103 Hospital (2004 - 2009). from June 2016 to April, 2017 to determine Military Medicine Journal. 2011, 3, pp.118- prognostic factors of tetanus disease. 121. This study result indicated that severe 6. Mekannen D. Tetanus in adults: clinical predictors of tetanus patients concluded: presentation, treatment and predictors of - The onset period was shorter than mortality in a tertiary hospital in Ethiopia., 24 hours. Journal of the Neurological Siences. 2012, - Trismus (the level of lockjaw) less than 317 (1 - 2), pp.62-65. 1 cm. 7. Pilaca A, Beqiri A, Ndreu A.H et al. - Presence of over 10 convulsions within Factors affecting the prognosis of Albanian 24 hours. adult patients with generalized tetanus. G Chir. 2012, 33 (4), pp.105-109. - Increase of sputum and sweat. 8. Ramachandra L. Shobha K.L. A retrospective - Frequency of pulse over 110 cycles clinical study of factorial tetanus. Journal of per minute. Microbiology. 2009, 7 (1), pp.23-40. 137