Tetanus Immunoglobulin Administration for Active Tetanus
Immediate Dosing for Established Tetanus Disease
For a patient with active tetanus disease, administer 3,000-6,000 units of human tetanus immunoglobulin (TIG) intramuscularly as soon as possible after diagnosis. 1
This therapeutic dose is dramatically higher than the 250 units used for wound prophylaxis and reflects the need to neutralize circulating tetanus toxin in established disease. 1
Route of Administration: Intramuscular vs. Intrathecal
While standard practice remains intramuscular administration, intrathecal TIG (250 IU) demonstrates superior outcomes and should be strongly considered, particularly in resource-limited settings or severe cases. 2
Evidence Supporting Intrathecal Administration:
Meta-analysis of 942 patients across 12 randomized trials showed intrathecal administration reduced mortality with a relative risk of 0.71 (95% CI, 0.62-0.81) compared to intramuscular administration. 3
In early tetanus, intrathecal TIG 250 IU resulted in only 1 death among 49 patients (2%), compared to 10 deaths among 48 patients (21%) receiving 1,000 IU intramuscularly. 4
For mild tetanus specifically, intrathecal TIG significantly reduced disease progression (p=0.05), hospital stay duration (p=0.01), ICU stay (p=0.05), need for tracheostomy (p=0.03), and sedative requirements (p=0.01). 5
The intrathecal route achieves high concentrations in cerebrospinal fluid around nerve roots where toxin binds, and was devoid of side effects in clinical trials. 4
Practical Administration Protocol:
- If using intrathecal route: Administer 250 IU via lumbar puncture. 5, 4
- If using intramuscular route: Administer 3,000-6,000 units IM. 1
- The superiority of intrathecal therapy emerged in both adults and neonates, and with both high and low doses. 3
Critical Concurrent Management
Active Immunization (Essential):
Simultaneously administer tetanus toxoid vaccine (Td preferred for adults ≥7 years) at a separate anatomic site using a separate syringe. 2, 1
- Natural tetanus infection provides absolutely no immunity—patients who survive remain fully susceptible to future infections unless actively immunized. 2
- Use only adsorbed toxoid when giving TIG and tetanus toxoid together. 2
Wound Management:
Perform immediate thorough surgical debridement of all necrotic tissue to eliminate anaerobic conditions that favor Clostridium tetani growth. 2
- Proper wound cleaning and debridement are as critical as immunization in tetanus management. 2
Airway Management:
Secure the airway immediately and prepare for mechanical ventilation, as respiratory failure from laryngospasm and respiratory muscle rigidity is the leading cause of death. 2
- Case fatality remains 18-21% even with modern intensive care, primarily due to respiratory complications and autonomic dysfunction. 2
Mechanism and Timing Considerations
TIG neutralizes circulating tetanus toxin but cannot neutralize toxin already bound to nerve endings—emphasizing the critical importance of early administration. 1
Administer TIG as soon as possible after diagnosis to maximize benefit. 1
Special Population Considerations
Older adults (>60 years) have significantly higher mortality from tetanus and should be prioritized if TIG supplies are limited, as they are less likely to have protective antibody levels. 2
Severely immunocompromised patients require TIG regardless of vaccination history. 2
Common Pitfalls to Avoid
Do not confuse prophylactic dosing (250 units for wound management) with therapeutic dosing (3,000-6,000 units for active disease). 1
Do not administer TIG and tetanus toxoid at the same anatomic site—always use separate syringes at different sites. 2, 1
Do not assume tetanus infection confers immunity—active immunization with tetanus toxoid is mandatory during acute management. 2
Do not delay TIG administration—the window for neutralizing circulating toxin is time-sensitive. 1