Tetanus Immunoglobulin Indications
Tetanus immunoglobulin (TIG) is indicated for patients with fewer than 3 documented tetanus toxoid doses OR unknown/uncertain vaccination history presenting with any wound, and for severely immunocompromised patients with contaminated wounds regardless of vaccination history. 1, 2
Primary Indications Based on Vaccination History
Patients Requiring TIG
Patients with <3 lifetime tetanus toxoid doses presenting with ANY wound (clean or contaminated) should receive both tetanus toxoid-containing vaccine AND TIG 250 units IM at separate anatomic sites using separate syringes. 1, 2
Patients with unknown or uncertain vaccination history should be treated as having zero previous doses and receive both tetanus toxoid and TIG, as it is not possible to assume adequate immunity without documentation. 1, 2
Severely immunocompromised patients (including those with HIV infection or severe immunodeficiency) with contaminated wounds should receive TIG regardless of their tetanus immunization history. 1, 3
Patients NOT Requiring TIG
Patients with ≥3 documented tetanus toxoid doses do NOT need TIG, regardless of wound type (clean or contaminated), unless they are severely immunocompromised. 1, 2
For patients with ≥3 doses and clean, minor wounds: give tetanus toxoid only if ≥10 years since last dose; no TIG needed. 1, 2
For patients with ≥3 doses and contaminated/tetanus-prone wounds: give tetanus toxoid only if ≥5 years since last dose; no TIG needed. 1, 2
Wound Classification Considerations
Tetanus-Prone Wounds
Contaminated/tetanus-prone wounds include puncture wounds, wounds contaminated with dirt/feces/soil/saliva, avulsions, and wounds from missiles, crushing, burns, or frostbite. 1, 2
These wounds determine the critical 5-year interval (rather than 10-year) for booster administration in adequately vaccinated patients. 1
Clean, Minor Wounds
- Clean, minor wounds in patients with ≥3 documented doses require only tetanus toxoid (if ≥10 years since last dose), never TIG. 1, 2
Dosing and Administration
Standard prophylactic dose: 250 units IM for both adults and children, with no weight-based dosing for prophylaxis. 1, 2
Always administer TIG and tetanus toxoid at separate anatomic sites using separate syringes to prevent interference with the immune response. 1, 2
Human TIG is strongly preferred over equine antitoxin due to longer protection and fewer adverse reactions. 1
Special Population Considerations
Elderly Patients
Patients ≥60 years old should be prioritized for TIG when supplies are limited, as 49-66% lack protective antibody levels. 1, 3
At least 40% of adults ≥60 years lack protective antibody levels; vaccination status must be assessed at every healthcare visit. 3
Immigrants
- Immigrants from regions outside North America/Europe should be prioritized for TIG in mass-casualty settings with limited supply, as they are less likely to have adequate vaccination history. 1
Pregnant Women
- Pregnant women requiring tetanus toxoid should receive Tdap regardless of prior Tdap history, but TIG indications remain the same (based on vaccination history and wound type). 1
Critical Clinical Pearls
Patients requiring TIG must complete a 3-dose primary tetanus vaccination series for long-term protection, as passive immunization does not confer lasting immunity. 1
The first dose of tetanus toxoid should be given concurrently with TIG (at a separate site) to initiate active immunization. 1, 2
Do not assume military service equals complete vaccination: patients with military service since 1941 can be considered to have received at least one dose, but completion of the primary series cannot be assumed. 2
In resource-limited settings, IVIG may be substituted for TIG when unavailable, though no direct dose equivalency exists and efficacy data are limited. 1
Common Pitfalls to Avoid
Do not give TIG to patients with ≥3 documented doses unless they are severely immunocompromised with contaminated wounds—this is unnecessary and wastes resources. 1, 2
Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds in adequately vaccinated patients—this is the most common error in tetanus prophylaxis. 1
Do not administer tetanus boosters more frequently than recommended, as this increases the risk of Arthus-type hypersensitivity reactions. 1
Proper wound cleaning and debridement are critical components of tetanus prevention in addition to immunization. 1