From the Guidelines
For a patient with a hand injury from barbed wire who completed tetanus vaccination 12 years ago, the best approach is option C: Tetanus toxoid plus immunoglobulin. Since the last dose was administered more than 10 years ago and the wound is potentially contaminated (barbed wire is considered a tetanus-prone injury), both active and passive immunization are recommended, as indicated by the guidelines from the Advisory Committee on Immunization Practices (ACIP) 1. The tetanus toxoid booster will stimulate the immune system to produce antibodies, but this takes time. The immunoglobulin provides immediate passive protection against tetanus while the body develops its own immune response. This dual approach is particularly important for tetanus-prone wounds when the last vaccination was over 5-10 years ago, as supported by the recommendations for postexposure interventions to prevent infection with tetanus in persons wounded during mass-casualty events 1. The wound should also be thoroughly cleaned and debrided to remove any foreign material that might harbor Clostridium tetani spores. This comprehensive approach provides both immediate and long-term protection against tetanus infection, which can be life-threatening if it develops. Key considerations include:
- The time since the last tetanus toxoid-containing vaccine dose, which in this case exceeds 10 years, necessitating a booster dose for a tetanus-prone wound 1.
- The nature of the wound, which is contaminated and thus requires both active (tetanus toxoid) and passive (immunoglobulin) immunization for optimal protection 1.
- The importance of using separate syringes and injection sites when administering tetanus toxoid and immunoglobulin concurrently, as recommended by the ACIP 1.
From the FDA Drug Label
For active tetanus immunization in wound management of patients 7 years of age and older, a preparation containing tetanus and diphtheria toxoids is preferred instead of single-antigen tetanus toxoid to enhance diphtheria protection. The need for active immunization with a tetanus toxoid-containing preparation, with or without passive immunization with Tetanus Immune Globulin (TIG) (Human) depends on both the condition of the wound and the patient's vaccination history. Table 1: Guide for use of Tetanus and Diphtheria Toxoids Adsorbed (Td) for Tetanus Prophylaxis in Routine Wound Management in Persons 7 Years of Age and Older History of Adsorbed Tetanus Toxoid (Doses) Clean, Minor Wounds All Other Wounds* Td TIG Td TIG
- Such as, but not limited to, wounds contaminated with dirt, puncture wounds and traumatic wounds ‡ Yes, if >10 years since last dose.
The patient has a wound contaminated with dirt (barbed wire) and has not received a tetanus toxoid dose in more than 10 years. According to the guidelines, for all other wounds (not clean, minor wounds), the patient should receive Td (Tetanus and Diphtheria Toxoids) and TIG (Tetanus Immune Globulin) if it has been more than 10 years since the last dose. Therefore, the best option is Tetanus + toxoid + immunoglobulin 2.
From the Research
Tetanus Prophylaxis
The patient has a hand injury from a barbed wire and received an anti-tetanus vaccine 12 years ago. Considering the time since the last dose, the best course of action would be:
- Tetanus toxoid (if the wound is clean)
- Tetanus immunoglobulin (if the wound is dirty or contaminated) 3, 4, 5
Rationale
The studies suggest that tetanus immunoglobulin is used along with vaccination for prevention of infection after major or contaminated wounds if vaccination status cannot be verified or for active tetanus infection 3. Additionally, tetanus infection may still occur in properly vaccinated individuals, and a protective tetanus antibody level should not preclude a patient from treatment of tetanus infection 6.
Treatment Options
The treatment options for tetanus infection include:
- Interrupting the production of toxin
- Neutralizing the unbound toxin
- Controlling muscle spasms
- Managing dysautonomia
- Appropriate supportive management 4 Specific therapy includes intramuscular administration of tetanus immunoglobulin to neutralize circulating toxin before it binds to neuronal cell membranes 4.
Post-Exposure Prophylaxis
Post-exposure prophylaxis (PEP) may be comprised of 1 or more vaccinations with the tetanus toxoid and/or the administration of tetanus immunoglobulin 5. The patient's vaccination history and the nature of the injury should be taken into account when determining the need for PEP.