Tetanus Immune Globulin (TIG) Recommendations
Tetanus immune globulin (TIG) is indicated for prophylaxis against tetanus following injury in patients whose immunization is incomplete or uncertain, and should be administered at a dose of 250 units intramuscularly for wounds that are contaminated, puncture wounds, or non-clean wounds when the patient has received fewer than 3 doses of tetanus toxoid or has uncertain vaccination history. 1
Indications for TIG Administration
The decision to administer TIG depends on two key factors:
Wound characteristics
- Clean, minor wounds: TIG not needed regardless of vaccination history
- All other wounds (contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; wounds from missiles, crushing, burns, frostbite): TIG needed if vaccination history is incomplete
Patient's tetanus vaccination history
- Fewer than 3 doses or uncertain history: TIG indicated for non-clean wounds
- 3 or more doses: TIG not indicated regardless of wound type
Algorithm for TIG Administration
| History of Tetanus Immunization | Clean, Minor Wounds | All Other Wounds | ||
|---|---|---|---|---|
| Td/Tdap | TIG | Td/Tdap | TIG | |
| Uncertain or <3 doses | Yes | No | Yes | Yes |
| ≥3 doses | No* | No | No** | No |
*Yes if >10 years since last dose **Yes if >5 years since last dose 1, 2
Dosage and Administration
- Adults and children ≥7 years: 250 units intramuscularly 1
- Children <7 years: Can calculate by body weight (4.0 units/kg), but administering the full 250 units is generally advised regardless of size 1
- When both TIG and tetanus toxoid-containing vaccine are indicated, they must be administered at different sites using separate syringes 2
Special Considerations
Incomplete Vaccination History
- Persons with unknown or uncertain tetanus vaccination histories should be considered to have had no previous tetanus toxoid doses 2
- A thorough attempt must be made to determine whether a patient has completed primary vaccination 1
- Military service since 1941 suggests at least one previous dose, but complete primary series cannot be assumed 1
Contraindications and Precautions
- History of severe allergic reaction to tetanus toxoid requires consultation with an allergist 2
- For individuals with history of Guillain-Barré syndrome within 6 weeks of previous tetanus vaccination, carefully evaluate risks and benefits 2
- History of Arthus reaction to previous tetanus toxoid-containing vaccine: defer for at least 10 years 2
Special Populations
- Immunocompromised patients: Should receive TIG regardless of vaccination history 2
- Pregnant women: Can receive TIG if indicated; Tdap is preferred for the tetanus toxoid component 2
Efficacy and Timing
Research confirms that following a tetanus toxoid booster in adults not immunized in the previous 10 years, there is no significant antitoxin response within the first 4 days 3. This validates the recommendation for TIG in tetanus-prone wounds when vaccination history is incomplete or uncertain.
Treatment of Active Tetanus
While primarily used for prophylaxis, TIG is also indicated in the treatment of active tetanus cases, though evidence of effectiveness is limited 1. For active tetanus, dosage should be adjusted according to infection severity 1.
Common Pitfalls to Avoid
- Failing to thoroughly assess vaccination history: Always make a careful attempt to determine previous tetanus vaccination status
- Relying solely on time since last dose: The number of previous doses is equally important
- Administering TIG and tetanus toxoid at the same site: Always use separate syringes and different anatomical sites
- Neglecting wound cleaning: Proper wound care remains paramount regardless of TIG administration
- Forgetting follow-up doses: When initiating vaccination series, emphasize the need for completing the full series (additional doses at 1 month and 1 year)
By following these evidence-based guidelines, clinicians can ensure appropriate tetanus prophylaxis while avoiding unnecessary TIG administration.