What is the recommended prescription for a tetanus toxoid shot?

Tetanus Toxoid Prescription Guidelines

For adults and adolescents ≥11 years requiring tetanus vaccination, prescribe Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine) 0.5 mL intramuscularly as a single dose if they have never received Tdap or their Tdap history is unknown; for those with documented prior Tdap, prescribe Td (tetanus-diphtheria toxoid) 0.5 mL intramuscularly. 1

Primary Vaccination Series (Never Previously Vaccinated)

For adults ≥18 years who have never been vaccinated against tetanus:

• Administer a 3-dose series: one dose of Tdap, followed by Td at least 4 weeks later, then another Td dose 6-12 months after the second dose 1
• Alternatively, Tdap can substitute for any of the three doses in the primary series, though the preferred schedule places Tdap first 1
• The series does not need to be restarted if doses are delayed—simply continue from where the patient left off 2

Routine Booster Vaccination

For fully vaccinated adults requiring routine boosters:

• Administer either Td or Tdap every 10 years after completing the primary series 1, 2
• Since 2019, ACIP guidelines allow flexibility: either Td or Tdap may be used for decennial boosters, whereas previously only Td was recommended after the initial Tdap 1, 2
• Adults ≥19 years who have never received Tdap should get one dose regardless of when they last received a tetanus-containing vaccine 1

Wound Management Prescriptions

For tetanus prophylaxis in wound management, the prescription depends on wound type and vaccination history:

Clean, Minor Wounds

• If ≥3 prior doses and last dose <10 years ago: No vaccine needed 1
• If ≥3 prior doses and last dose ≥10 years ago: Prescribe Tdap 0.5 mL IM (if never received Tdap) or Td 0.5 mL IM (if prior Tdap documented) 1
• If <3 prior doses or unknown history: Prescribe Tdap 0.5 mL IM (preferred) or Td 0.5 mL IM 1

Contaminated/Tetanus-Prone Wounds

(Wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; crush injuries; burns) 1

• If ≥3 prior doses and last dose <5 years ago: No vaccine needed 1, 3
• If ≥3 prior doses and last dose ≥5 years ago: Prescribe Tdap 0.5 mL IM (if never received Tdap) or Td 0.5 mL IM (if prior Tdap documented) 1, 3
• If <3 prior doses or unknown history: Prescribe BOTH Tdap 0.5 mL IM AND Tetanus Immune Globulin (TIG) 250 units IM at separate anatomic sites 1, 3

Special Populations

Pregnant Women

• Prescribe Tdap 0.5 mL IM during each pregnancy between 27-36 weeks' gestation, preferably during the earlier part of this period, regardless of prior vaccination history 2
• If tetanus toxoid-containing vaccine is indicated for wound management in a pregnant woman, Tdap should be used 1

Elderly Adults (≥65 Years)

• Prescribe Tdap 0.5 mL IM for those who have never received Tdap, regardless of interval since last tetanus-containing vaccine 1, 2
• When feasible, Boostrix should be used for adults ≥65 years, though either Tdap product is acceptable 1, 2
• Continue Td or Tdap boosters every 10 years 2

Immunocompromised Patients

• For contaminated wounds in patients with HIV infection or severe immunodeficiency, prescribe BOTH tetanus toxoid-containing vaccine AND TIG 250 units IM regardless of tetanus immunization history 3

Product Selection and Administration

Available formulations:

• Tdap vaccines: Boostrix (approved ≥10 years) or Adacel (approved 10-64 years) 1
• Td vaccine: Standard tetanus-diphtheria toxoid 1
• Dose: 0.5 mL intramuscularly 4
• Route: Deltoid muscle in adults and older children; anterolateral thigh in infants <1 year 4

Critical Pitfalls to Avoid

• Do NOT administer tetanus boosters more frequently than every 10 years for routine immunization, as this can cause Arthus reactions (severe local hypersensitivity) 2, 3
• Do NOT confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds—this is the most common error in tetanus prophylaxis 2, 3
• Do NOT use DTaP in persons ≥7 years; use Tdap or Td instead 2, 4
• Do NOT restart the vaccination series if doses are delayed; simply continue from where the patient left off 2
• For patients with a history of Arthus reaction following a previous tetanus toxoid dose, do NOT administer tetanus toxoid-containing vaccine until >10 years after the most recent dose, even for contaminated wounds 2, 3

Contraindications

Absolute contraindication: Severe allergic reaction (anaphylaxis) after a previous dose of any tetanus toxoid or diphtheria toxoid-containing vaccine, or to any vaccine component 4

Documentation

Maintain a personal vaccination record documenting vaccine type, manufacturer, anatomic site, route, date of administration, and administering facility name to minimize unnecessary vaccinations 3