Tetanus Prophylaxis for Adult Dirty Wounds
For an adult with a dirty (contaminated) wound, administer a tetanus-containing vaccine (Tdap preferred if not previously received, otherwise Td) if ≥5 years have elapsed since the last dose; tetanus immune globulin (TIG) 250 units IM is ONLY required if the patient has <3 documented lifetime doses or unknown vaccination history. 1, 2
Vaccination Algorithm Based on Immunization History
Patients with ≥3 Previous Doses (Complete Primary Series)
Last dose <5 years ago: No tetanus vaccine or TIG needed—the patient is fully protected 2, 3
Last dose ≥5 years ago: Administer tetanus-containing vaccine WITHOUT TIG 1, 2
Patients with <3 Previous Doses or Unknown History
- Administer BOTH tetanus-containing vaccine (Tdap preferred) AND TIG 250 units IM 1, 2, 3
- Use separate syringes at different anatomic sites (e.g., one in each deltoid) 1, 2, 3
- These patients must complete a 3-dose primary series: second dose ≥4 weeks after first, third dose 6-12 months after second 2
- Persons with unknown or uncertain vaccination histories should be treated as having zero previous doses 1, 2
Critical Distinction: The 5-Year vs 10-Year Rule
This is the most common error in tetanus prophylaxis: 2
- Clean, minor wounds: Booster needed only if ≥10 years since last dose 1, 2
- Contaminated/tetanus-prone wounds (dirty wounds): Booster needed if ≥5 years since last dose 1, 2, 4
Dirty wounds include those contaminated with dirt, feces, soil, saliva, puncture wounds, and traumatic wounds 3, 5. The 5-year interval for contaminated wounds reflects the higher risk environment for Clostridium tetani spore germination 2.
Dosing Specifications
Tetanus Toxoid-Containing Vaccine
- Dose: 0.5 mL intramuscularly, preferably in the deltoid muscle 5
- Tdap preferred for adults ≥11 years who have not previously received Tdap 1, 2
Tetanus Immune Globulin (TIG)
- Prophylactic dose: 250 units IM for both adults and children (not weight-based) 2, 3
- Human TIG is strongly preferred over equine antitoxin due to longer protection and fewer adverse reactions 2
- Must be administered at a separate anatomic site from tetanus toxoid using a separate syringe 1, 2, 3, 5
Special Populations Requiring TIG Regardless of Vaccination History
- Severely immunocompromised patients (HIV infection, severe immunodeficiency) with contaminated wounds should receive TIG even if fully vaccinated 2, 3
- Pregnant women requiring tetanus prophylaxis should receive Tdap regardless of prior Tdap history 2
Important Clinical Caveats
Arthus Reaction History
- Patients with a history of Arthus-type hypersensitivity reaction following previous tetanus toxoid should NOT receive tetanus-containing vaccine until >10 years after the most recent dose, even with dirty wounds 1, 2
- The decision to administer TIG is still based on the primary vaccination history (Table in guidelines) 1
Timing and Urgency
- Research demonstrates no early antitoxin response within 4 days of tetanus booster administration, confirming that TIG recommendations for inadequately immunized patients are appropriate 6
- There is no urgency for tetanus toxoid administration in the acute setting, as it provides protection against future injuries, not the current one 7
- However, TIG (when indicated) should be administered promptly as it provides immediate passive immunity 3
Avoiding Overimmunization
- More frequent doses than recommended increase the risk of adverse reactions, including Arthus-type hypersensitivity reactions 1, 2, 5
- The most common error is giving tetanus toxoid to patients with complete immunization who received a booster <5 years ago for dirty wounds (or <10 years for clean wounds) 8
Resource-Limited Settings
In mass-casualty situations with limited TIG supply, prioritize administration to: 2, 3, 9
- Patients >60 years of age (49-66% lack protective antibody levels)
- Immigrants from regions outside North America/Europe (less likely to have adequate vaccination history)