What is the recommended treatment for tetanus post-exposure?

Tetanus Post-Exposure Prophylaxis

For tetanus post-exposure prophylaxis, immediately perform thorough wound debridement, then administer tetanus toxoid-containing vaccine (Tdap preferred for adults who haven't received it; Td for those >65 years) if the last dose was ≥5 years ago for contaminated wounds or ≥10 years ago for clean minor wounds, and add Tetanus Immune Globulin (TIG) 250 units IM only if the patient has <3 lifetime doses or unknown vaccination history. 1, 2

Wound Management First

• Proper wound cleaning and surgical debridement are the most critical first steps in tetanus prevention, as they remove the anaerobic environment where Clostridium tetani spores germinate 1, 3, 4
• Tetanus-prone wounds include puncture wounds, wounds from projectiles or crushing injuries, avulsions, burns, and wounds contaminated with dirt, feces, soil, or saliva 1
• Antibiotic prophylaxis is NOT indicated for tetanus prevention in most wounds 5

Vaccination Algorithm Based on Wound Type and History

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

Clean, Minor Wounds:

• Give tetanus toxoid ONLY if ≥10 years since last dose 1, 5, 2
• NO TIG needed 1, 2

Contaminated/Tetanus-Prone Wounds:

• Give tetanus toxoid if ≥5 years since last dose 1, 5, 2, 6
• NO TIG needed 1, 2
• This 5-year interval is the most commonly missed detail in clinical practice 5

For Patients with <3 Previous Doses or Unknown History:

• Give BOTH tetanus toxoid AND TIG 250 units IM for ALL wounds 1, 5, 2
• Administer at separate anatomic sites using separate syringes 1, 2
• Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses 1, 2

Vaccine Selection

• Tdap is strongly preferred over Td for adults ≥11 years who have not previously received Tdap or whose Tdap history is unknown, as this provides additional protection against pertussis 1, 5
• For adults >65 years, Td is preferred 1, 5
• For children <7 years: use DTaP 1
• For children 7-10 years: use Td 1
• For children ≥11 years: use Tdap (or Td if Tdap unavailable) 1

Tetanus Immune Globulin (TIG) Administration

Dosing:

• Standard prophylactic dose: 250 units IM for adults and children 1, 2
• For small children, may calculate 4.0 units/kg, but advisable to give entire 250 units regardless of size 2

Priority Groups When TIG Supply is Limited:

• Persons aged >60 years (49%-66% lack protective antibody levels) 1, 5
• Immigrants from regions other than North America or Europe 1, 4

Special Populations Requiring TIG Regardless of Vaccination History:

• Severely immunocompromised patients (HIV infection, severe immunodeficiency) with contaminated wounds 1, 5

Critical Timing Considerations

• Tetanus toxoid provides protection against the NEXT injury, not the current injury 7
• There is no urgency for tetanus toxoid administration in the acute setting 7
• However, TIG must be given promptly as it provides immediate passive immunity 3
• Persons who received at least two doses of tetanus toxoid rapidly develop antibodies after a booster 1, 5

Common 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 5
• Do NOT administer tetanus vaccine to patients with active tetanus infection, as it provides no benefit for treating established infection 3
• More frequent doses than recommended may increase adverse reactions, including Arthus-type hypersensitivity reactions 1, 5
• Patients with history of Arthus reaction should not receive tetanus toxoid until >10 years after most recent dose 5

Follow-Up Requirements

• Patients receiving TIG must complete a 3-dose primary tetanus vaccination series for long-term protection 5
• For previously unvaccinated adults: first dose (Tdap preferred), second dose at ≥4 weeks, third dose at 6-12 months 5
• After complete primary series, boosters every 10 years maintain adequate protection 1, 5
• Tetanus infection does NOT confer natural immunity—patients must complete full immunization series after recovery 3

Special Clinical Scenarios

Mass-Casualty Settings:

• Any tetanus vaccine formulation may be used if age-appropriate vaccines unavailable, as tetanus toxoid content is adequate for all ages 1
• If DTaP supplies inadequate, substitute Tdap or Td for children 1

Pregnant Women:

• Tdap should be used regardless of prior Tdap history when tetanus toxoid is indicated 5

Case Fatality:

• Tetanus remains highly lethal with 18-21% case-fatality rate even with modern medical care 1, 3, 4
• Elderly patients have higher mortality rates 3