Effectiveness of Intrathecal Tetanus Immunoglobulin in Postneonatal Tetanus: A Retrospective Comparative Study (TIG-TET Study)

Postneonatal tetanus remains a significant cause of mortality and morbidity in low- and middle-income countries (LMICs). Intrathecal human tetanus immunoglobulin (ITIG) has emerged as a potential therapeutic option; however, its efficacy and safety remain unclear. This retrospective study was conducted in a Level-3 pediatric intensive care unit (PICU) in North India over 19 years (2006-2024) that included 63 children (ages 1 month-12 years) with postneonatal tetanus. Beginning in 2012, we began using ITIG (1,000 U within 24 hours of admission) in addition to standard treatment. Children who received ITIG (n = 39) were compared with those who did not receive ITIG (n = 24) (ITIG and no-ITIG group, respectively). The primary outcome was in-hospital mortality, and secondary outcomes were length of mechanical ventilation, PICU stay, and complication rates. The median (interquartile range) age was 7 (3-9) years, 77.8% were boys, and none were fully immunized. The main portals of entry were injury (47.6%) and otogenic (36.5%). The majority had generalized tetanus (96.8%) with a severity grade of 3b (79.4%). Common complications included respiratory failure (98.4%), autonomic dysfunction (79.4%), and rhabdomyolysis (66.6%). The ITIG group was associated with significantly lower mortality (10.3% vs. 50%, P = 0.001), similar durations of ventilation and PICU stay, and reduced rates of rhabdomyolysis, shock, and acute kidney injury. Administration of ITIG in postneonatal tetanus in an LMIC setting was associated with significantly lower mortality and complications. There is a need to conduct trials to evaluate the efficacy of ITIG in postneonatal tetanus, especially in LMICs, where disease burden and the cost of intensive care are significant considerations.