What is the best course of action for a patient with a hand injury from a barbed wire, who received their last tetanus (Tetanus Toxoid) vaccine 12 years ago?

From the Guidelines

For a patient with a hand injury from barbed wire who completed tetanus vaccination 12 years ago, the best approach is to administer tetanus toxoid (TT) or Tdap (Tetanus, diphtheria, and acellular pertussis) vaccine. Since the patient has been previously immunized but the last dose was more than 10 years ago, a booster dose is recommended 1. The Centers for Disease Control and Prevention guidelines suggest tetanus boosters every 10 years for previously immunized individuals. In the case of a potentially contaminated wound like a barbed wire injury, a booster is particularly important if more than 5 years have elapsed since the last dose. Some key points to consider in this scenario include:

• The patient's previous immunization history, which suggests they have some residual immunity against tetanus 1.
• The type of wound, which is a hand injury from barbed wire, indicating a potentially contaminated wound that may require a tetanus booster 1.
• The time elapsed since the last tetanus toxoid-containing vaccine dose, which is 12 years in this case, exceeding the recommended 10-year interval for boosters 1. Tetanus immunoglobulin is not necessary for this patient because they have a history of complete immunization, even though it was 12 years ago. The patient likely has some residual immunity, and the booster will rapidly increase antibody levels. Antiserum toxin is an outdated term and not used in current practice, while combining toxoid with immunoglobulin would be excessive for someone with previous immunization history. The most recent and highest quality study, published in 2020, supports the use of Tdap for persons aged ≥11 years who have not previously received Tdap or whose Tdap history is unknown 1. Therefore, administering tetanus toxoid (TT) or Tdap (Tetanus, diphtheria, and acellular pertussis) vaccine is the best approach for this patient.

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 a dirty object (barbed wire) and has completed the primary immunization series more than 10 years ago. According to the guidelines, for all other wounds (not clean, minor wounds), if the patient has had ≥ three doses of tetanus toxoid and it has been >10 years since the last dose, the recommended treatment is Td (tetanus and diphtheria toxoids) and TIG (Tetanus Immune Globulin). Therefore, the best option is C. 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 is not sufficient on its own as the patient's vaccination status is outdated 3
• Immunoglobulin may be necessary to provide immediate protection against tetanus infection 4, 5
• Tetanus + toxoid + immunoglobulin may be the most comprehensive approach to prevent tetanus infection, especially since the patient's injury is from a potentially contaminated source 6, 5
• Antiserum toxin is not a standard treatment for tetanus prophylaxis, and tetanus immunoglobulin is preferred 4, 5

Key Considerations

• The patient's vaccination history and time since the last dose are crucial in determining the best course of action 3, 6
• The type of injury and potential contamination also play a role in deciding the treatment approach 6, 5
• Tetanus immunoglobulin can provide immediate protection against tetanus infection, while tetanus toxoid provides long-term immunity 4, 5