What are the guidelines for the prevention and treatment of tetanus?

Tetanus Prevention and Treatment Guidelines

Primary Prevention Through Vaccination

All infants and children should receive a 5-dose series of DTaP vaccine (at 2,4,6,15-18 months, and 4-6 years), followed by a single Tdap booster at age 11-12 years, with subsequent Td boosters every 10 years throughout adulthood. 1

Routine Vaccination Schedule

• Children <7 years: Complete 5-dose DTaP series as outlined above 1
• Adolescents (11-12 years): Single Tdap dose regardless of interval since last Td 1
• Adults who never received Tdap: One-time Tdap dose, then Td every 10 years 1
• Pregnant women: Tdap during each pregnancy at 27-36 weeks' gestation, regardless of previous Tdap receipt 1

Special Population Considerations

• Adults ≥60 years: At least 40% lack protective antibody levels; vaccination status must be assessed at every healthcare visit 1
• Uncertain vaccination history: Treat as unvaccinated and initiate complete 3-dose primary series 2
• Post-tetanus infection: Active vaccination must begin during recovery, as tetanus infection does not confer immunity 3

---

Wound Management and Tetanus Prophylaxis

The decision to administer tetanus prophylaxis depends on two critical factors: the patient's vaccination history and wound classification (clean/minor vs. contaminated/tetanus-prone).

Wound Classification

• Clean, minor wounds: Simple lacerations with minimal contamination 2
• Contaminated/tetanus-prone wounds: Puncture wounds, wounds contaminated with dirt/feces/soil/saliva, crush injuries, burns, frostbite, wounds requiring surgical debridement 4, 2

Prophylaxis Algorithm for Patients with ≥3 Previous Doses

Clean, Minor Wounds:

• Last dose <10 years ago: No vaccine or TIG needed 4
• Last dose ≥10 years ago: Administer tetanus toxoid-containing vaccine only 2

Contaminated/Tetanus-Prone Wounds:

• Last dose <5 years ago: No vaccine or TIG needed 4
• Last dose ≥5 years ago: Administer tetanus toxoid-containing vaccine WITHOUT TIG 4
• Use Tdap if patient has not previously received Tdap or Tdap history is unknown 4

Prophylaxis Algorithm for Patients with <3 Doses or Unknown History

All Wounds:

• Administer BOTH tetanus toxoid-containing vaccine AND TIG (250 units IM) 2
• Complete the 3-dose primary series subsequently 4
• Administer vaccine and TIG at separate injection sites using separate syringes 2

Critical Clinical Pearls

• The 5-year interval applies only to contaminated wounds; do not confuse this with the 10-year routine booster interval 4
• Tdap is strongly preferred over Td for adults who have not received Tdap, providing additional pertussis protection 4
• For pregnant women requiring tetanus prophylaxis, always use Tdap regardless of prior Tdap history 4

---

Special Populations Requiring Modified Approach

Immunocompromised Patients

• HIV infection or severe immunodeficiency: Administer TIG regardless of tetanus immunization history for all contaminated wounds 4
• Standard vaccination schedules may not produce adequate immune response 5

Elderly Patients (≥60 years)

• Higher risk of tetanus infection and mortality (case-fatality ratio 8-21%) 2
• Lower prevalence of protective antibodies (only 21% of women >70 years have protection) 2
• Prioritize TIG for tetanus-prone wounds with uncertain vaccination history 2

Patients with History of Arthus Reaction

• Do not administer tetanus toxoid-containing vaccine until >10 years after most recent dose, regardless of wound severity 4

---

Treatment of Active Tetanus

Immediate Management

Tetanus is a medical emergency requiring intensive care with focus on airway management, muscle spasm control, wound debridement, and passive/active immunization.

• Wound care: Thorough surgical debridement of necrotic tissue to remove anaerobic conditions favorable for C. tetani growth 2
• Human Tetanus Immune Globulin (TIG): 250 units IM for prophylaxis; higher doses (3,000-6,000 units) may be used for treatment 2
• Tetanus toxoid: Initiate active immunization concurrently at separate site 2

Muscle Spasm Control

• Diazepam: 5-10 mg IM or IV initially, then 5-10 mg every 3-4 hours as needed 6
• For severe tetanus, larger doses may be required 6
• Respiratory assistance must be readily available 6
• In children ≥5 years: 5-10 mg repeated every 3-4 hours as needed 6
• In infants >30 days: 1-2 mg IM or IV slowly, repeated every 3-4 hours 6

Supportive Care

• Antibiotics (metronidazole or penicillin) to eliminate C. tetani 7
• Intensive care monitoring for autonomic instability 7
• Mechanical ventilation for respiratory failure 7

---

Common Pitfalls to Avoid

• Do not assume tetanus infection provides immunity: Vaccination is required even after recovery 3
• Do not administer unnecessary boosters: More frequent doses than recommended increase risk of Arthus-type hypersensitivity reactions 4
• Do not delay wound debridement: Proper wound care is as critical as immunization 2
• Do not use small veins for IV diazepam: Avoid dorsum of hand or wrist; extreme care needed to prevent intra-arterial administration 6
• Do not mix diazepam with other solutions: Administer separately 6