From the Guidelines
A patient with a nail injury who received a tetanus vaccine 12 years ago should be given a tetanus booster (Td or Tdap) and tetanus immune globulin (TIG) because the wound is a puncture wound and it has been more than 10 years since the last tetanus immunization. According to the most recent guidelines from the Advisory Committee on Immunization Practices (ACIP) 1, a tetanus toxoid-containing vaccine is indicated as part of wound management if more than 5 years has passed since the last tetanus toxoid-containing vaccine dose, and TIG is recommended for contaminated wounds. The standard adult dose of Td or Tdap is 0.5 mL administered intramuscularly, preferably in the deltoid muscle, and TIG should be administered at a dose of 250 units intramuscularly at a different site from the tetanus toxoid.
- Key considerations for tetanus prophylaxis in wound management include:
- Determining the patient's previous tetanus vaccination history
- Assessing the wound type and contamination level
- Administering a tetanus toxoid-containing vaccine and TIG as indicated
- Ensuring proper wound cleaning and debridement to remove foreign material and devitalized tissue that might harbor tetanus spores
- The guidelines emphasize the importance of preventing tetanus infection, which can cause severe muscle spasms and potentially death, by administering tetanus toxoid-containing vaccines and TIG as part of standard wound management 1.
- It is essential to follow the recommended schedule for tetanus toxoid-containing vaccine administration, with booster doses given every 10 years, to maintain adequate protection against tetanus infection 1.
From the FDA Drug Label
Available evidence indicates that complete primary vaccination with tetanus toxoid provides long lasting protection ≥10 years for most recipients. Consequently, after complete primary tetanus vaccination, boosters-even for wound management-need be given only every 10 years when wounds are minor and uncontaminated For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding 5 years. 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.
The patient has a nail injury and received a tetanus toxoid vaccine 12 years ago.
- The patient's wound is likely to be considered other than clean and minor (a puncture wound from a nail).
- The patient has had at least one dose of tetanus toxoid (actually, they completed primary vaccination) more than 5 years ago (12 years ago). According to the table, for other wounds and a history of ≥ three doses, the patient should receive Td and TIG if it has been more than 5 years since the last dose. Therefore, the patient should receive tetanus toxoid (Td) and tetanus immunoglobulin (TIG), which corresponds to option D. 2 3
From the Research
Patient with Nail Injury and Previous Tetanus Vaccination
The patient has a nail injury and received a tetanus toxoid vaccine 12 years ago. Considering the options:
- A-Tetanous toxoid
- B-tetanous immunoglobulin
- C-tetanus antiserm
- D-tetanous toxoid and immunoglobulin
Recommended Course of Action
Based on the studies, the following points are relevant:
- Tetanus immune globulin (TIG) is recommended for persons with tetanus-prone wounds who have incomplete or unknown tetanus immunization status 4.
- The antitoxin response to tetanus toxoid booster may not be sufficient within 4 days of vaccination, especially if the previous vaccination was more than 10 years ago 4.
- Primary immunization with tetanus toxoid provides protection for at least 5 years, and a booster dose can extend this protection for up to 10 years 5.
- Even patients who had their last booster more than 10 years ago may still have satisfactory immunoglobulin levels 6.
- Combined active and passive prophylaxis with human tetanus immune globulin can provide adequate protection 7.
Decision
Given that the patient's last tetanus vaccination was 12 years ago, and considering the nail injury is a tetanus-prone wound, the most appropriate option would be to administer tetanus toxoid and immunoglobulin (option D) to provide both immediate and long-term protection against tetanus 4, 5, 7.