Tetanus Immune Globulin (TIG) Dosing
For routine post-exposure prophylaxis, administer 250 units of tetanus immune globulin (TIG) intramuscularly for both adults and children aged 7 years or older, and either 250 units or 4.0 units/kg (though 250 units is advisable regardless of size) for children under 7 years. 1
Routine Post-Exposure Prophylaxis Dosing
Adults and Children ≥7 Years
- Standard dose: 250 units IM 1
- Administer via deep intramuscular injection
- Must be given in a different extremity from tetanus toxoid using a separate syringe
- Simultaneously administer Td (tetanus-diphtheria toxoid) vaccine according to manufacturer guidelines
Children <7 Years
- Weight-based calculation: 4.0 units/kg 1
- However, it is advisable to administer the full 250 units regardless of child's size, as the same amount of toxin will theoretically be produced by the tetanus organism regardless of body size 1
- Administer with DTP or DT (if pertussis contraindicated) in a different extremity with separate syringe
When TIG is Indicated
The FDA-approved indications specify TIG use based on wound characteristics and vaccination history 1:
TIG is required when:
- Patient has uncertain/incomplete tetanus immunization history (<3 doses) AND has wounds that are NOT clean and minor
- This includes wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; wounds from missiles, crushing, burns, or frostbite 1
TIG is NOT needed when:
- Patient has completed primary series (≥3 doses) regardless of wound type
- Patient has clean, minor wounds regardless of vaccination status 1
Critical Timing Considerations
- For fully vaccinated patients with non-clean wounds: Td booster only needed if >5 years since last dose
- For fully vaccinated patients with clean, minor wounds: Td booster only needed if >10 years since last dose 1
Treatment of Active Tetanus
For established tetanus disease, dosing must be adjusted according to severity of infection 1. The FDA label states standard therapy must be implemented immediately but does not specify exact doses, indicating clinical judgment based on disease severity is required. Historical literature suggests higher doses (3,000-6,000 units) have been used for treatment, though this is not explicitly stated in current FDA labeling.
Important Clinical Pitfalls
Wound care is paramount - TIG is adjunctive to proper debridement and wound management 1. Approximately 10% of tetanus cases have no identifiable wound, so maintain clinical suspicion even without obvious injury 1.
Surveillance data reveals prophylaxis failures: Among patients with wounds eligible for post-exposure prophylaxis, only 2.3% received TIG and only 26% received TTCV per recommendations 2. This represents a critical gap in adherence to guidelines.
Active immunization must be completed: The single TIG injection provides only passive immunity. Patients must complete the full tetanus toxoid series (additional doses at 1 month and 1 year) or the active immunization remains incomplete 1.
Contraindication scenario: If tetanus toxoid is contraindicated in a patient with incomplete primary series who has a non-clean/non-minor wound, give ONLY passive immunization with TIG 1.