What is the recommended approach to tetanus prophylaxis and treatment for a patient with a wound, including assessment of immunization status, administration of tetanus‑containing vaccine (Td or Tdap), tetanus immune globulin (TIG), antibiotics, wound care, and management of established tetanus?

Tetanus Prophylaxis and Management

Wound Classification Determines Vaccination Timing

For contaminated/tetanus-prone wounds (puncture wounds, soil contamination, animal bites, penetrating injuries), administer tetanus toxoid if ≥5 years have elapsed since the last dose; for clean, minor wounds, administer only if ≥10 years have elapsed. 1

Tetanus-Prone Wounds Include:

• Puncture wounds and penetrating injuries that create anaerobic environments 1
• Wounds contaminated with dirt, soil, feces, or saliva 1
• Animal bites (including cat and dog bites) 1
• Burns (excluding first-degree burns, which do not harbor tetanus spores) 1
• Nail penetration injuries 1

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Vaccination Algorithm Based on Immunization History

Patients with ≥3 Previous Doses (Complete Primary Series)

Clean, Minor Wounds:

• If last dose <10 years ago: No vaccine or TIG needed 1
• If last dose ≥10 years ago: Give tetanus toxoid (Tdap preferred if never received Tdap or history unknown) WITHOUT TIG 1

Contaminated/Tetanus-Prone Wounds:

• If last dose <5 years ago: No vaccine or TIG needed 1
• If last dose ≥5 years ago: Give tetanus toxoid (Tdap preferred if never received Tdap or history unknown) WITHOUT TIG 1

Patients with <3 Previous Doses or Unknown History

Any Wound Type:

• Give BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM at separate anatomic sites using separate syringes 1
• Treat patients with unknown or uncertain vaccination history as having zero previous doses 1
• Complete the 3-dose primary series: second dose ≥4 weeks after first, third dose 6-12 months after second 1

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Tetanus Immune Globulin (TIG) Administration

TIG 250 units IM is indicated only for:

• Patients with <3 documented lifetime tetanus doses presenting with any wound 1
• Patients with unknown/uncertain vaccination history presenting with any wound 1
• Severely immunocompromised patients (HIV infection, severe immunodeficiency) with contaminated wounds, regardless of vaccination history 1

Critical Administration Details:

• Always administer TIG and tetanus toxoid at separate anatomic sites using separate syringes 1
• The 250-unit dose is universal for both adults and children (not weight-based) 1
• Human TIG is strongly preferred over equine antitoxin due to longer protection and fewer adverse reactions 1, 2
• In mass-casualty settings with limited TIG supply, prioritize patients >60 years and immigrants from regions outside North America/Europe 1

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Vaccine Selection: Tdap vs. Td

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

Special Populations:

• Pregnant women: Use Tdap regardless of prior Tdap history when tetanus toxoid is indicated for wound management 1
• Adults >65 years: Td is preferred for routine boosters, but Tdap should still be used if never previously received 1
• Healthcare personnel: Should receive a single dose of Tdap as soon as feasible if not previously received 1

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Wound Care Essentials

Proper wound cleaning and surgical debridement of necrotic tissue are critical components of tetanus prevention in addition to vaccination. 1, 3

• Remove all contaminated material, dirt, and debris that may harbor Clostridium tetani spores 3
• Create aerobic conditions unfavorable for bacterial growth 3
• Antibiotic prophylaxis is NOT indicated for tetanus prevention in most wounds 1

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Management of Established Tetanus

Immediate Interventions (Within Hours of Diagnosis)

Administer human TIG 250-500 units IM immediately to neutralize circulating tetanospasmin that has not yet bound to neural tissue. 3

• TIG cannot reverse damage from toxin already bound to the central nervous system 3
• Do not delay TIG administration while awaiting laboratory confirmation—tetanus is a clinical diagnosis 3
• Use separate injection sites if administering TIG concurrently with tetanus toxoid 3

Eliminate Toxin Source

• Perform thorough surgical debridement of all wounds to remove necrotic tissue 3, 2
• Initiate antibiotic therapy immediately: Metronidazole 500 mg IV every 6-8 hours (preferred) OR Penicillin G 2-4 million units IV every 4-6 hours for 7-14 days 3
• Metronidazole is preferred over penicillin due to its GABA antagonist properties 3

Supportive Care

• Implement early respiratory support with mechanical ventilation for respiratory compromise 2
• Monitor and manage autonomic instability (associated with high mortality) 2
• Monitor for rhabdomyolysis due to severe muscle spasms 2
• Administer tetanus toxoid vaccine as part of treatment, since natural infection does not confer immunity 3

Post-Recovery Immunization

Patients must complete a full primary immunization series after recovery, as tetanus does not confer natural immunity. 2

• First dose: Tdap (preferred) 2
• Second dose: Td or Tdap at least 4 weeks after first dose 2
• Third dose: Td or Tdap 6-12 months after second dose 2

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Critical 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 in tetanus prophylaxis. 1

• More frequent doses than recommended increase the risk of Arthus-type hypersensitivity reactions 1
• Patients with a history of Arthus reaction should not receive tetanus toxoid until >10 years after the most recent dose, even with contaminated wounds 1
• Do not restart the vaccination series if doses are delayed—simply continue from where the patient left off 1
• Elderly patients (≥60 years) are at higher risk: 49-66% lack protective antibody levels 1
• Failure to provide tetanus vaccination when needed could result in preventable illness, whereas unnecessary vaccination is unlikely to cause harm 1

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Prognostic Considerations

• Mortality rate for tetanus ranges from 5-50% even with modern intensive care 3
• Case-fatality rate remains 18-21% in developed countries with full ICU support 3, 2
• Higher mortality rates occur in elderly patients and those with severe disease 3
• Only 21% of women >70 years have protective antibody levels 3