What are the guidelines for tetanus (Td) prophylaxis?

Tetanus Prophylaxis Guidelines

Wound Classification Determines Timing

The critical decision in tetanus prophylaxis is wound classification: clean/minor wounds require boosters only if ≥10 years since last dose, while contaminated/tetanus-prone wounds (puncture wounds, wounds contaminated with dirt/soil/saliva, crush injuries, burns) require boosters if ≥5 years since last dose. 1, 2

Clean, Minor Wounds

• Administer tetanus toxoid-containing vaccine only if ≥10 years since last dose 1, 2
• No TIG required regardless of timing 1

Contaminated/Tetanus-Prone Wounds

• Administer tetanus toxoid-containing vaccine if ≥5 years since last dose 1, 2
• Examples include: puncture wounds, wounds contaminated with dirt/feces/soil/saliva, avulsions, crush injuries, burns, frostbite 1
• No TIG required if patient has ≥3 documented doses 1, 2

Vaccination History Algorithm

Patients with ≥3 Previous Doses (Complete Primary Series)

• Clean, minor wounds: Give Td/Tdap only if ≥10 years since last dose 1, 2
• Contaminated wounds: Give Td/Tdap only if ≥5 years since last dose 1, 2
• TIG is NOT needed regardless of wound type 1, 2
• Complete primary vaccination provides nearly 100% protection and long-lasting immunity for at least 10 years 1

Patients with <3 Doses or Unknown History

• All wounds: Give BOTH tetanus toxoid-containing vaccine AND TIG 250 units IM 1, 2
• Administer at separate anatomic sites using separate syringes 1
• Treat unknown/uncertain vaccination history as zero previous doses 1, 2
• Complete the 3-dose primary series: second dose ≥4 weeks after first, third dose 6-12 months after second 3

Vaccine Selection by Age and History

Adults ≥11 Years

• Tdap is strongly preferred over Td if patient has not previously received Tdap or Tdap history is unknown 1, 2
• Tdap provides additional protection against pertussis, which is critical given adult pertussis transmission 1
• For nonpregnant persons with documented previous Tdap, use Td for subsequent boosters 1

Pregnant Women

• Always use Tdap if tetanus toxoid-containing vaccine is indicated, regardless of prior Tdap history 1, 2
• Tdap should be given during each pregnancy at 27-36 weeks gestation 2

Children <7 Years

• Use DTaP for routine wound management 1
• Use DT only if pertussis vaccine is contraindicated 1

Special Populations Requiring TIG

Immunocompromised Patients

• HIV infection or severe immunodeficiency: Give TIG regardless of tetanus immunization history when contaminated wounds are present 1, 2
• This is the primary exception to the "≥3 doses = no TIG" rule 1

Elderly Patients (≥60-65 Years)

• Prioritize for TIG if supplies are limited 2, 4
• Only 21% of women >70 years have protective antibody levels 4, 5
• 38% of tetanus cases occur in patients ≥65 years despite lower injury rates 4, 6
• Average annual incidence is twice as high in those ≥65 years (0.23 per million) compared to ages 21-64 (0.10 per million) 7, 6

Critical Clinical Pitfalls

Most Common Error: Confusing the 5-Year and 10-Year Intervals

• Do not give boosters at 3-year intervals or more frequently than recommended 2
• More frequent doses increase risk of Arthus-type hypersensitivity reactions 2
• The 10-year routine booster interval is separate from the 5-year contaminated wound interval 2

Missed Prophylaxis Opportunities

• In California 2008-2014, among 9 tetanus patients who sought medical care for acute injury, only 2 (22%) received appropriate prophylaxis 7
• Of 51 patients with acute wounds and complete surveillance data, 49 (96.1%) had not received appropriate prophylaxis 6
• A 2024 case report documented generalized tetanus in a 79-year-old woman whose last booster was 7 years prior to a high-risk agricultural injury—she should have received Td/Tdap immediately but did not 8

Arthus Reaction History

• Patients with history of Arthus reaction should not receive tetanus toxoid-containing vaccine until >10 years after most recent dose, regardless of wound severity 2

Wound Management Essentials

Immediate Interventions

• Thorough wound cleaning and debridement are critical first steps 1, 4
• Remove all debris that might harbor Clostridium tetani spores 4
• Surgical debridement of necrotic tissue creates aerobic conditions unfavorable for bacterial growth 4, 5

What NOT to Do

• Antibiotic prophylaxis is NOT indicated for tetanus prevention in most wounds 2
• Do not delay tetanus toxoid administration—there is no urgency as it protects against future injuries, not current injury 9
• Do not restart vaccination series if doses are delayed; simply continue from where patient left off 2

Primary Vaccination Series for Unvaccinated Adults

Three-Dose Schedule

• First dose: Tdap preferred 3
• Second dose: ≥4 weeks (minimum 2 months) after first dose 3
• Third dose: 6-12 months after second dose 3
• After completion, boosters every 10 years throughout life 2

TIG Administration Details

Dosing and Technique

• Standard prophylactic dose: 250 units IM 1, 4
• For established tetanus cases: 250-500 units IM 5
• Human TIG is preferred over equine antitoxin (longer protection, fewer adverse reactions) 1, 5
• When giving TIG and tetanus toxoid concurrently, use separate syringes at different anatomical sites 1, 3

Limitations

• TIG cannot reverse damage from toxin already bound to central nervous system 5
• Provides passive immunity only; patient still needs active immunization with tetanus toxoid 4, 5

Prognosis and Disease Burden

• Case-fatality rate remains 13-18% even with modern intensive care 5, 7, 6
• Higher mortality in elderly patients and those with severe disease 4, 5
• Natural tetanus infection does not confer immunity; vaccination still required after recovery 5
• Complete primary vaccination is nearly 100% effective in preventing tetanus 1, 4