If scratched by a rusty nail, how soon should a tetanus (Td or Tdap) booster be administered?

Tetanus Prophylaxis After Rusty Nail Injury

For a rusty nail scratch, tetanus prophylaxis should be administered within 5 years of the last tetanus vaccination for optimal protection against tetanus infection. 1, 2

Tetanus Prophylaxis Based on Vaccination History

For Fully Immunized Individuals (completed primary series)

• If last tetanus vaccination was <5 years ago: No tetanus toxoid-containing vaccine or TIG needed 1, 3
• If last tetanus vaccination was ≥5 years but <10 years ago: Administer tetanus toxoid-containing vaccine (Tdap or Td) without TIG 4, 3
• If last tetanus vaccination was ≥10 years ago: Administer tetanus toxoid-containing vaccine (Tdap or Td) 4

For Individuals with Unknown or Incomplete Vaccination History

• Administer both tetanus toxoid-containing vaccine AND tetanus immune globulin (TIG) immediately 3, 4
• TIG dose is 250 units administered intramuscularly 4, 3
• When both TIG and tetanus toxoid-containing vaccine are indicated, administer using separate syringes at different anatomical sites 4, 3

Vaccine Selection Guidelines

• For persons aged ≥11 years who have not previously received Tdap or have unknown Tdap history, Tdap is preferred over Td 4, 1
• For persons with documented previous Tdap vaccination, Td should be used 4, 1
• For pregnant women requiring tetanus prophylaxis, Tdap should be used regardless of prior Tdap history 4, 1

Special Considerations

• Rusty nails create puncture wounds that are considered tetanus-prone due to the anaerobic environment they create, which is ideal for Clostridium tetani growth 5, 2
• The rust itself is not the source of tetanus bacteria, but rather the contamination with soil or dust containing tetanus spores 5
• Persons with a history of an Arthus reaction following a previous tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose 4, 1
• Immunocompromised individuals should receive TIG regardless of their tetanus immunization history 1, 2

Clinical Pearls and Pitfalls

• There is no urgency for administering tetanus toxoid in the acute setting for fully immunized individuals with up-to-date vaccinations, as it provides protection against future injuries rather than the current injury 6
• Wound cleaning and debridement are crucial components of tetanus prevention 1, 4
• The incubation period for tetanus is typically 3-21 days, with an average of 8 days, making prompt prophylaxis important 7
• Studies show that tetanus vaccination coverage is insufficient in adults, especially those ≥60 years of age, with only about 54% of adults reporting having received a tetanus vaccine in the last 10 years 8, 9

Long-term Protection

• After receiving appropriate tetanus prophylaxis for the wound, subsequent booster doses should be administered every 10 years throughout life 4, 10
• For adults who have never been vaccinated against tetanus, a complete 3-dose primary series should be initiated, with the first dose being Tdap 4, 1