Failure of intrathecal antitetanus serum to improve survival in neonatal tetanus

SUMMARY In a prospective study, 161 infants with neonatal tetanus were randomised to receive (a) standard treatment, or (b) standard treatment together with intrathecal equine antitetanus serum, or (c) intrathecal antitetanus serum with systemic betamethasone. There was no difference in survival between the three treatment groups in infants with severe tetanus, but in mild tetanus those who received standard treatment alone had an improved survival rate. Parenteral intramuscular diazepam as a sedative was found to be preferable to paraldehyde, as the latter was associated with a higher incidence of secondary infections. Neonatal tetanus is still a major cause of neonatal death in many countries, with reported mortality in patients in hospital ranging between 55 and 86%.1 Management in many such countries consists of administration of equine antitetanus serum (ATS) or human tetanus hyperimmune globulin (TIGH) in combination with sedatives and antibiotics, as resources and staff are generally not available for mechanical respiratory support. In recent years there has been a revival of interest in the use of intrathecally-administered ATS. Its use was abandoned in the 1940s owing to the high incidence of complications,2 but recent reports have shown that combined with steroids it can be given safely. Initial studies reported favourably on the use of either intrathecal ATS or TIGH.3-4 In an effort to reduce the high mortality rate associated with neonatal tetanus, we decided to evaluate intrathecal ATS as an adjunct to our standard treatment in a controlled study. We hoped that this might be a useful and easy adjunct to treatment, even in small rural hospitals. Patients and method