When to use Tdap (Tetanus, diphtheria, and pertussis) vs TIG (Tetanus Immunoglobulin) for wound management?

Tetanus Prevention and Wound Management: Tdap vs TIG

For tetanus prevention in wound management, TIG (Tetanus Immunoglobulin) should be administered for patients with unknown or fewer than 3 doses of tetanus vaccine who present with contaminated wounds, while Tdap (or age-appropriate tetanus toxoid-containing vaccine) should be given based on vaccination history regardless of wound type. 1, 2

Decision Algorithm for Tetanus Prophylaxis

Step 1: Assess Vaccination History

• Complete vaccination history (3+ doses):

  • For clean, minor wounds: No TIG needed; Tetanus toxoid-containing vaccine only if >10 years since last dose
  • For contaminated wounds*: No TIG needed; Tetanus toxoid-containing vaccine only if >5 years since last dose 1, 2

• Unknown or incomplete vaccination (<3 doses):

  • For clean, minor wounds: Tetanus toxoid-containing vaccine only (No TIG)
  • For contaminated wounds*: BOTH Tetanus toxoid-containing vaccine AND TIG 1, 2

*Contaminated wounds include those with dirt, feces, soil, saliva, puncture wounds, avulsions, and wounds from missiles, crushing, burns, or frostbite.

Step 2: Select Appropriate Tetanus Toxoid-Containing Vaccine

• Children <7 years: DTaP
• Children 7-10 years: Td
• Persons ≥11 years: Tdap (preferred if not previously received) 1

Special Considerations

Immunocompromised Patients

• Patients with immunocompromising conditions (including HIV) should receive TIG for contaminated wounds regardless of tetanus immunization history 1, 3
• Recent evidence shows attenuated immune responses to Tdap in pregnant women with HIV, which could affect protection of their infants 3

Pregnant Women

• Pregnant women should receive Tdap if tetanus prophylaxis is indicated
• Optimal timing is between 27-36 weeks gestation (preferably earlier in this window)
• Can be safely given at any time during pregnancy if needed for wound management 1, 4

Administration Guidelines

• When both TIG and tetanus toxoid-containing vaccine are needed:
  • Administer using separate syringes
  • Use different anatomical sites
  • Standard prophylactic TIG dose: 250 units intramuscularly 1

Important Clinical Pearls

• TIG provides immediate passive immunity for the current wound, while tetanus toxoid-containing vaccines (Tdap/Td/DTaP) provide active immunity for future protection 1, 5
• It is not clinically possible to reliably determine which wounds are tetanus-prone, as tetanus can occur after minor injuries yet is rare after severely contaminated wounds 5
• Immediate and thorough wound cleaning is critical for tetanus prevention 1
• The case-fatality rate for tetanus remains high at approximately 25%, with higher rates in older adults 1

Common Pitfalls to Avoid

1. Overuse of TIG: Reserve TIG for patients with unknown or incomplete vaccination history with contaminated wounds, or immunocompromised patients 1, 2

2. Incorrect vaccine selection: Use age-appropriate vaccines (DTaP for children <7 years, Td for children 7-10 years, and Tdap for persons ≥11 years) 1

3. Ignoring contraindications: Avoid pertussis-containing vaccines in patients with history of encephalopathy within 7 days of previous pertussis vaccination or Guillain-Barré syndrome within 6 weeks of previous tetanus toxoid-containing vaccine 1

4. Delaying vaccination in pregnant women: Tdap can be safely administered during pregnancy for wound management 1, 4