What is the recommended dose of tetanus immunoglobulin (TIG) for post-exposure prophylaxis?

Tetanus Immunoglobulin Dosing for Post-Exposure Prophylaxis

The recommended prophylactic dose of tetanus immunoglobulin (TIG) for post-exposure prophylaxis is 250 units administered intramuscularly (IM) for both adult and pediatric patients with tetanus-prone wounds. 1, 2

Indications for TIG Administration

TIG is indicated in the following situations:

• Patients with tetanus-prone wounds who have:

  • Unknown vaccination history 1, 2
  • Incomplete primary tetanus vaccination series (<3 doses) 1, 2
  • Uncertain vaccination status 1

• Tetanus-prone wounds include:

  • Contaminated wounds (dirt, feces, soil, saliva) 2
  • Puncture wounds 2
  • Avulsions 2
  • Wounds from missiles, crushing, burns, and frostbite 2

Administration Guidelines

• TIG should be administered at the time of wound management 1

• When tetanus toxoid (Td/Tdap) and TIG are administered concurrently:

  • Use separate syringes 1
  • Inject at separate anatomical sites 1, 2
  • The use of adsorbed toxoid is considered mandatory in this situation 1

• In mass-casualty settings with limited TIG supply, priority should be given to:

  • Persons aged >60 years 1
  • Immigrants from regions other than North America or Europe 1, 2
  • These populations are less likely to have adequate antitetanus antibodies 1

Special Populations

• Immunocompromised patients:

  • Persons with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history if they have contaminated wounds 2

• Pregnant women:

  • Follow the same TIG guidelines as non-pregnant adults 2
  • Although no evidence suggests tetanus toxoids are teratogenic, waiting until the second trimester for Td administration is a reasonable precaution 1

Alternative Options

• In circumstances where TIG is unavailable, intravenous immune globulin (IVIG) may be substituted 1
• However, there are no data available about the efficacy of IVIG when used for tetanus prophylaxis 1

Important Considerations

• Postexposure antimicrobial prophylaxis against tetanus is not recommended 1, 2
• For clean, minor wounds, TIG is not needed regardless of vaccination history 2
• Early administration of TIG is crucial as studies show no significant increase in tetanus antitoxin levels within the first 4 days following a tetanus toxoid booster 3
• Intrathecal administration of TIG (250 IU) has shown benefit in treating early tetanus by reducing disease progression and mortality, but this is for treatment rather than prophylaxis 4, 5

Common Pitfalls to Avoid

• Failing to administer TIG when indicated can lead to preventable tetanus cases 6
• Relying solely on the time since last tetanus vaccination without determining the total number of previous doses received 1
• Not using separate injection sites and syringes when administering TIG and tetanus toxoid concurrently 1
• Administering TIG to patients with a history of severe Arthus-type hypersensitivity reactions to tetanus toxoid within the past 10 years 2

Remember that TIG provides immediate passive protection while tetanus toxoid vaccination stimulates active immunity that develops over time. Both are often needed for optimal protection in patients with tetanus-prone wounds and inadequate vaccination history.