What is the next step in tetanus prophylaxis for a patient with a foot injury caused by a wooden object, whose last tetanus toxoid (TT) vaccine was administered 12 years ago?

From the Guidelines

The patient should receive both tetanus toxoid and tetanus immunoglobulin for immediate and long-term protection against tetanus infection. For a patient with a foot injury from a piece of wood who received their last tetanus vaccine 12 years ago, the administration of both tetanus toxoid and tetanus immunoglobulin is necessary due to the contaminated nature of the wound and the time elapsed since the last vaccination 1. The tetanus toxoid will stimulate the patient's immune system to produce antibodies against tetanus toxin, providing long-term protection, but this takes time to develop. The tetanus immunoglobulin provides immediate passive immunity by delivering pre-formed antibodies that can neutralize any tetanus toxin already present in the wound. This dual approach is necessary because the patient is considered inadequately immunized against tetanus due to the long interval since their last vaccination, and the wound is potentially contaminated with Clostridium tetani spores, which can lead to severe muscle spasms and potentially fatal complications 1. Key considerations include:

• The patient's last tetanus vaccination was more than 10 years ago, indicating a need for a booster dose.
• The wound is contaminated with wood, which can harbor Clostridium tetani spores, necessitating immediate passive immunization with tetanus immunoglobulin.
• The combination of tetanus toxoid and immunoglobulin provides both immediate and long-term protection against tetanus infection. Given these considerations and the guidelines for tetanus prophylaxis in wound management 1, the most appropriate course of action is to administer both tetanus toxoid and tetanus immunoglobulin to ensure the patient's safety and prevent potential complications from tetanus infection.

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 † If only three doses of fluid tetanus toxoid have been received, then a fourth dose of toxoid, preferably an adsorbed toxoid should be given. ‡ 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 foot injury by a piece of wood, which is considered a wound contaminated with dirt.
• The patient's last dose of tetanus vaccine was received 12 years back.
• According to Table 1, for a patient with ≥ Three doses of tetanus toxoid and an All Other Wounds*, Td and TIG are recommended if it has been >10 years since last dose.
• Since it has been 12 years since the patient's last dose, Td and TIG are recommended.
• Therefore, the patient should receive Tetanus toxoid + immunoglobulin 2.

From the Research

Tetanus Prophylaxis

The patient has a foot injury caused by a piece of wood and has not received a tetanus vaccine in the last 12 years.

• The patient's last dose of tetanus vaccine was 12 years ago, which indicates that their immunity may have waned 3, 4, 5.
• According to the studies, tetanus prophylaxis is essential in preventing tetanus infection, especially in patients with wounds 4, 5, 6.
• The patient should receive tetanus toxoid to boost their immunity, as well as tetanus immunoglobulin to provide immediate protection against tetanus toxin 3, 5.

Recommended Treatment

• The recommended treatment for the patient would be to administer tetanus toxoid and tetanus immunoglobulin 3, 5.
• This combination provides both immediate and long-term protection against tetanus infection 4, 7.
• It is essential to follow the guidelines for tetanus prophylaxis to ensure that the patient receives adequate protection against tetanus infection 5, 6.