Aggressive Intensive Care Treatment of Very Elderly Patients with Tetanus Is Justified: DISCUSSION
Generalized tetanus has become very rare in developed countries because of successful active immunization programs. For instance, by September 1986, only 46 cases had been reported to the Centers for Disease Control for 1985 in the United States, information quite consistent with our incidence of 0.07 cases per 100,000 per year in Geneva between 1968 and 1989. However, С tetani remains ubiquitous in the soil and in the gastrointestinal tract of man and many domesticated animals. Elderly individuals are frequently inadequately protected against tetanus, either because they had never received a full course of immunization or because they had not received booster injections of tetanus toxoid. Our elderly patients with generalized tetanus had a negative history for tetanus vaccination, as did patients in many reported series, which is consistent with the poor protection of many elderly adults against tetanus when assessed by serologic studies.
Mortality rates for tetanus have varied widely (7 to 60 percent) over the years in developed countries, but, in the modern intensive care unit, sophisticated nursing care, sedation, neuromuscular blockade, and assisted ventilation via tracheostomy have decreased the mortality rate to around 10 percent. In these series, death more often results from sympathetic instability, nosocomial infection, or mechanical ventilation complications. In previously published series, mortality seems related to age: 30 percent of young adults and 60 percent of elderly patients died in the United States before 1970 and the modern intensive care unit era. Nowadays, elderly patients seem to fare as well as young adults.
However, the prognosis of very old patients such as those in our series has seldom been studied, and there is, to our knowledge, no comparison in terms of mortality and medical sequelae between young and old patients with tetanus. The favorable outcome of elderly patients suffering from tetanus in the modern era of the intensive care unit is not really a surprise: when we consider the outcome of old patients admitted for whatever reason to the intensive care unit after 1980, the survival rate is quite good and not very different from those of younger people. This may be due to a “selection bias,” very old persons representing a time-selected healthy subpopulation whose complete recovery from an intensive care unit stay can be expected as long as vital organ function can be preserved, which is the case for a self-resolving illness like tetanus.
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In summary, our data strongly favor aggressive intensive care unit treatment of elderly patients with generalized, severe tetanus: even after prolonged complete neuromuscular blockade, recovery can be complete, and the quality of life can be similar to what it had been before this severe illness. There is no valid reason to reject very elderly people from intensive care treatment of tetanus when they are in their 80s.
