What is the recommended treatment for tetanus post-exposure?

Tetanus Post-Exposure Prophylaxis

Immediate Wound Management

Thorough 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

• This applies to all patients with tetanus-prone wounds regardless of vaccination status 1
• Tetanus-prone wounds include puncture wounds, wounds from projectiles or crushing injuries, avulsions, burns, and wounds contaminated with dirt, feces, soil, or saliva 1

Vaccination Decision Algorithm

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). 2

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

Clean, Minor Wounds:

• Give tetanus toxoid ONLY if ≥10 years since last dose 1, 2
• NO TIG needed 1, 2
• Tdap strongly preferred over Td for adults ≥11 years who have not previously received Tdap or whose Tdap history is unknown 1

Contaminated/Tetanus-Prone Wounds:

• Give tetanus toxoid if ≥5 years since last dose 1, 2
• NO TIG needed 1, 2
• Tdap strongly preferred over Td for adults ≥11 years who have not previously received Tdap or whose Tdap history is unknown 1

For Patients with <3 Previous 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 2
• Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses 2
• These patients must complete a 3-dose primary vaccination series for long-term protection 1

Vaccine Selection by Age

• Children <7 years: DTaP 1
• Children 7-10 years: Td 1
• Children ≥11 years and adults: Tdap preferred (or Td if Tdap unavailable) 1
• Adults >65 years: Td preferred 1

Tetanus Immune Globulin (TIG) Dosing

The standard prophylactic dose is 250 units IM for both adults and children. 1, 2

• In small children, the dose may be calculated by body weight (4.0 units/kg), but it is advisable to administer the entire 250 units regardless of the child's size 2
• When giving TIG and tetanus toxoid concurrently, use separate syringes at different anatomical sites 2

Special Populations Requiring TIG Regardless of Vaccination History

Severely immunocompromised patients (HIV infection, severe immunodeficiency) with contaminated wounds require TIG regardless of vaccination history. 1

• Priority groups for TIG include 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

Critical Clinical Pearls and Common Pitfalls

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. 3

• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions 3
• Patients with a history of Arthus reaction should not receive tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound severity 3
• Antibiotic prophylaxis is NOT indicated for tetanus prevention 3
• Tetanus infection does not confer immunity; active vaccination must begin during recovery 4
• At least 40% of adults ≥60 years lack protective antibody levels; vaccination status must be assessed at every healthcare visit 4

Pregnant Women

If tetanus toxoid-containing vaccine is indicated for pregnant women, Tdap should be used regardless of prior Tdap history. 1

• Pregnant women should receive Tdap during EACH pregnancy at 27-36 weeks gestation, regardless of prior Tdap history 3

Case Example Highlighting Missed Prophylaxis

A 79-year-old woman with proper vaccination (last booster 7 years prior) sustained a contaminated wound from an iron pipe during agricultural work and developed generalized tetanus because TTV was not administered during initial wound care. 5 Since her last tetanus booster was administered more than 5 years prior to the high-risk injury, prophylaxis with TTV should have been promptly administered. 5