When can you give antitetanus (tetanus) prophylaxis?

When to Give Antitetanus Prophylaxis

Administer tetanus toxoid-containing vaccine (preferably Tdap) for contaminated/tetanus-prone wounds if ≥5 years have elapsed since the last dose, and for clean, minor wounds if ≥10 years have elapsed; add tetanus immunoglobulin (TIG) 250 units IM only if the patient has <3 lifetime doses or unknown vaccination history. 1, 2, 3

Wound Classification

The first critical step is determining wound type, as this dictates the time interval for booster administration 1, 2:

• Clean, minor wounds: Simple, uncontaminated injuries 4, 3
• Tetanus-prone/contaminated wounds: Wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; wounds from missiles, crushing, burns, frostbite; or injuries involving metal objects in rural settings 1, 2, 3

Vaccination Algorithm Based on Immunization History

For Patients with ≥3 Previous Doses (Complete Primary Series)

Clean, minor wounds:

• Give tetanus toxoid-containing vaccine ONLY if ≥10 years since last dose 4, 1, 3
• NO TIG needed 1, 3

Contaminated/tetanus-prone wounds:

• Give tetanus toxoid-containing vaccine if ≥5 years since last dose 4, 1, 2, 3
• NO TIG needed (complete primary series provides adequate protection) 1, 3
• This 5-year interval is the most commonly missed detail in clinical practice 2

For Patients with <3 Previous Doses or Unknown History

All wounds (both clean and contaminated):

• Give BOTH tetanus toxoid-containing vaccine AND TIG 250 units IM 4, 1, 3
• Administer at separate anatomical sites using separate syringes 4, 1, 3
• Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses 4, 5

Vaccine Selection: Tdap vs Td

Tdap is strongly preferred over Td for the following patients 1, 2, 5:

• Persons ≥11 years who have not previously received Tdap or whose Tdap history is unknown 1, 2, 5
• This provides additional protection against pertussis, not just tetanus and diphtheria 2, 5

For pregnant women:

• Always use Tdap when tetanus prophylaxis is indicated, regardless of prior Tdap history 2, 5

For non-pregnant persons with documented previous Tdap:

• Either Td or Tdap may be used 2, 5

Special Populations Requiring TIG Regardless of Vaccination History

• Persons with HIV infection or severe immunodeficiency who have contaminated wounds should receive TIG regardless of their tetanus immunization history 1, 2, 5
• In mass-casualty settings with limited TIG supply, prioritize persons aged >60 years and immigrants from regions other than North America or Europe, as they are less likely to have adequate antitetanus antibodies 1, 2

Critical Contraindications and Timing Considerations

• Patients with a history of Arthus reaction following a previous tetanus toxoid dose should NOT receive tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound condition 1, 2, 5
• There is no urgency for tetanus toxoid administration in the acute setting, as it provides protection against the next injury, not the current injury 6
• However, failure to provide appropriate prophylaxis when indicated can result in preventable tetanus, as documented in case reports where patients with high-risk wounds and >5 years since last booster developed tetanus 7, 8

Common Clinical Pitfalls to Avoid

• Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds - this is the most common error 2
• Do not give TIG to patients with documented complete primary vaccination series (≥3 doses) unless they are severely immunocompromised 2, 5
• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions 1, 2
• Chemoprophylaxis with antibiotics against tetanus is NOT recommended or useful 4, 1

Wound Management Essentials

• Proper wound cleaning and debridement are crucial components of tetanus prevention and are of paramount importance 4, 5, 3
• The use of antitoxin is adjunctive to proper wound care 3
• In approximately 10% of tetanus cases, no wound or breach in skin could be implicated, emphasizing the importance of maintaining routine vaccination schedules 3

Completing the Primary Series

• Patients requiring both vaccine and TIG should ultimately complete a 3-dose primary series 2
• For adults lacking a complete primary series: give three doses with the first two doses at least 4 weeks apart, and the third dose 6-12 months after the second 2
• If doses are delayed, continue from where the patient left off - do not restart the series 2