When is tetanus (Td or Tdap) prophylaxis recommended after a burn?

Tetanus Prophylaxis After Burns

Burns are considered tetanus-prone wounds and require tetanus prophylaxis based on the patient's vaccination history, with a tetanus toxoid-containing vaccine indicated if more than 5 years have passed since the last dose. 1

Classification of Burns as Tetanus-Prone Wounds

Burns are explicitly classified as tetanus-prone wounds by the Advisory Committee on Immunization Practices (ACIP). According to the CDC guidelines, tetanus-prone wounds include:

• Burns
• Wounds contaminated with dirt, feces, soil, or saliva
• Puncture wounds
• Avulsions
• Wounds resulting from missiles, crushing, and frostbite 1

Burns create an environment where anaerobic Clostridium tetani can thrive, particularly when they involve necrotic tissue.

Tetanus Prophylaxis Algorithm for Burns

Step 1: Assess vaccination history

• Determine if patient has completed a 3-dose primary tetanus vaccination series
• If vaccination history is unknown or uncertain, consider the patient to have had no previous tetanus toxoid doses 1

Step 2: Provide appropriate wound care

• Proper wound cleaning and debridement are critical components of tetanus prevention 1
• Remove all necrotic tissue which can create anaerobic conditions favorable for C. tetani growth 2

Step 3: Administer tetanus prophylaxis based on vaccination history

For patients with complete primary vaccination (≥3 doses):

• If last tetanus toxoid-containing vaccine was <5 years ago: No tetanus toxoid or TIG needed
• If last tetanus toxoid-containing vaccine was ≥5 years ago: Administer tetanus toxoid-containing vaccine only (no TIG) 1

For patients with unknown/uncertain history or <3 doses:

• Administer both tetanus toxoid-containing vaccine AND Tetanus Immune Globulin (TIG) 1
• TIG dose: 250 units IM 1

Step 4: Select appropriate tetanus toxoid-containing vaccine

• For children <7 years: DTaP
• For persons 7-10 years: Td
• For persons ≥11 years who have not previously received Tdap: Tdap preferred
• For persons ≥11 years with previous Tdap: Td
• For pregnant women: Tdap 1

Special Considerations

Immunocompromised Patients

Persons with HIV infection or severe immunodeficiency who have contaminated wounds (including burns) should receive TIG regardless of their history of tetanus immunizations 1

Previous Adverse Reactions

Persons with a history of an Arthus reaction following a previous dose of tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of the wound condition 1

Administration of TIG and Tetanus Toxoid

When both TIG and tetanus toxoid are indicated, they should be administered using separate syringes at different anatomical sites 1, 3

Common Pitfalls to Avoid

1. Underestimating minor burns: Even seemingly minor burns can lead to tetanus if contaminated 4

2. Delaying wound care: Proper cleaning and debridement are as important as immunization 1

3. Overuse of TIG: Reserve TIG for patients with unknown/incomplete vaccination history or immunocompromised patients 1

4. Assuming military service guarantees complete vaccination: While persons who served in the military since 1941 likely received at least one dose, complete primary vaccination cannot be assumed 3

5. Neglecting follow-up: Ensure patients complete their primary vaccination series if it was previously incomplete 1

The evidence clearly supports that burns should be treated as tetanus-prone wounds requiring appropriate prophylaxis based on the patient's vaccination history, with particular attention to proper wound care and debridement.