From the Guidelines
For a patient with a hand injury from barbed wire who completed tetanus vaccination 12 years ago, the best approach is to administer tetanus toxoid (TT) or Tdap (Tetanus, diphtheria, and acellular pertussis) booster. Since the last dose was more than 10 years ago, immunity has likely waned below protective levels 1. A booster dose is sufficient because the patient has been previously immunized, creating memory B cells that can be rapidly activated.
Key Considerations
- Tetanus immunoglobulin is not necessary in this case because the patient has a history of complete immunization, even though it was 12 years ago 1.
- The wound from barbed wire is considered potentially contaminated, but the patient's immune system can mount a rapid response with just a booster.
- Antiserum toxin is an outdated term and not used in modern practice.
- Tetanus toxoid alone (or preferably Tdap) will stimulate the immune system to produce protective antibodies quickly enough to prevent tetanus infection from the current injury.
Recommendations
- According to the Advisory Committee on Immunization Practices (ACIP), a tetanus toxoid–containing vaccine is indicated for wound management when >5 years have passed since the last tetanus toxoid–containing vaccine dose 1.
- If a tetanus toxoid–containing vaccine is indicated for persons aged ≥11 years, Tdap is preferred for persons who have not previously received Tdap or whose Tdap history is unknown 1.
From the FDA Drug Label
For active tetanus immunization in wound management of patients 7 years of age and older, a preparation containing tetanus and diphtheria toxoids is preferred instead of single-antigen tetanus toxoid to enhance diphtheria protection. The need for active immunization with a tetanus toxoid-containing preparation, with or without passive immunization with Tetanus Immune Globulin (TIG) (Human) depends on both the condition of the wound and the patient's vaccination history. Table 1: Guide for use of Tetanus and Diphtheria Toxoids Adsorbed (Td) for Tetanus Prophylaxis in Routine Wound Management in Persons 7 Years of Age and Older History of Adsorbed Tetanus Toxoid (Doses) Clean, Minor Wounds All Other Wounds* Td TIG Td TIG
- Such as, but not limited to, wounds contaminated with dirt, puncture wounds and traumatic wounds ‡ Yes, if >10 years since last dose. § Yes, if >5 years since last dose. Unknown or < three Yes No Yes Yes ≥ Three† No‡ No No§ No
The patient has a dirty wound (hand injury by a barbed wire) and has not received a tetanus toxoid dose in more than 10 years.
- Td (Tetanus and Diphtheria Toxoids Adsorbed) is recommended for active immunization.
- TIG (Tetanus Immune Globulin) is also recommended for passive immunization because the wound is dirty. Therefore, the best option is C. Tetanus + toxoid + immunoglobulin 2 3.
From the Research
Tetanus Prophylaxis for Hand Injury
- The patient has a hand injury caused by a barbed wire and received anti-tetanus vaccine 12 years ago.
- The best course of action would be to administer a booster dose of tetanus toxoid, as the patient's last dose was 12 years ago 4, 5.
- This is because tetanus toxoid is effective in preventing tetanus infection, and a booster dose is recommended every 10 years to maintain immunity.
- There is no indication that the patient needs tetanus immunoglobulin or antiserum, as these are typically reserved for patients who have not been previously vaccinated or have a high risk of tetanus infection 6, 7.
Considerations for Tetanus Prophylaxis
- The patient's immune status and history of tetanus vaccination are important factors in determining the best course of action for tetanus prophylaxis 8.
- The use of tetanus toxoid as a booster dose is supported by studies that demonstrate its effectiveness in preventing tetanus infection 6, 7.
- The management of hand injuries, including tetanus prophylaxis, is an important aspect of emergency care, and healthcare providers should be aware of the latest guidelines and recommendations 4, 5.