What is the best treatment 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 last dose was more than 10 years ago, a booster dose is necessary as immunity wanes over time. The Centers for Disease Control and Prevention recommends tetanus boosters every 10 years for adults with a history of completed primary immunization, as indicated in the study 1. For contaminated wounds like those from barbed wire, which carry a higher risk of tetanus, boosters are recommended if the last dose was more than 5 years ago. Some key points to consider in the management of such cases include:

• The patient's previous immunization history, which in this case is 12 years ago, suggests the need for a booster to ensure adequate protection against tetanus 1.
• The type of wound, in this case, a hand injury from barbed wire, which is considered contaminated and thus at higher risk for tetanus infection.
• The current guidelines from the Advisory Committee on Immunization Practices (ACIP) as of 2018, which recommend the use of Tdap for persons who have not previously received Tdap or whose Tdap history is unknown, and Td for nonpregnant persons with documentation of previous vaccination with Tdap 1. Tetanus immunoglobulin is not necessary in this case because the patient has previously been immunized, even though it was 12 years ago. The patient still has some baseline immunity, and a booster dose will rapidly increase antibody levels. Tetanus toxoid alone will provide adequate protection by stimulating the immune system to produce antibodies against tetanus toxin, preventing the development of tetanus infection from the wound. Given the options provided, the best choice is A. Tetanus toxoid, as it directly addresses the need for a booster dose to prevent tetanus infection in a patient with a contaminated wound and a history of completed primary tetanus vaccination series more than 5 years ago, as supported by the guidelines 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 † If only three doses of fluid tetanus toxoid have been received, then a fourth dose of toxoid, preferably an adsorbed toxoid should be given. ‡ Yes, if >10 years since last dose. § Yes, if >5 years since last dose. Unknown or < three Yes No Yes Yes ≥ Three† No‡ No No§ No

The patient has a history of receiving anti-tetanus vaccine and completing it 12 years ago. Given that the patient has a hand injury from a barbed wire, which is considered a wound contaminated with dirt, the best option would be:

• Td (Tetanus toxoid): Yes, since it has been more than 10 years since the last dose.
• TIG (Tetanus Immune Globulin): No, since the patient has a history of receiving anti-tetanus vaccine and completing it.

Therefore, the best option is C. Tetanus toxoid+ immunoglobulin is not necessary, but A. Tetanus toxoid is necessary, and the patient may also require B. Immunoglobulin depending on the wound condition, but according to the table, for a patient with 3 or more doses of tetanus toxoid, and the wound is not clean and minor, Td is given, and TIG is given if the wound is not clean and minor and it has been more than 5 years since the last dose, in this case, it has been more than 10 years, so TIG should be given. So the correct answer 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 elapsed since the last dose, the best option for tetanus prophylaxis would be:

• Tetanus toxoid, as it is the standard recommendation for individuals who have not received a booster dose in the last 10 years 3
• Alternatively, tetanus toxoid + immunoglobulin could be considered, especially if the patient has a high-risk wound or has not received primary vaccination series 4

Rationale

The studies suggest that:

• Tetanus toxoid is effective in inducing immunity against tetanus, and its performance is dependent on the manufacturer 5
• Simultaneous injection of tetanus immunoglobulin with tetanus vaccine may not significantly influence the formation of tetanus antibody at late periods, but there may be differences at early periods or in older adults 3
• Monoclonal antibodies against tetanus toxin and toxoid have been developed, but their clinical application is limited 6
• New methods for detecting tetanus toxoid, such as fluorescent immunochromatography test strips, are being developed 7
• Intrathecal administration of tetanus antitoxin may be beneficial in reducing the need for mechanical ventilation in patients with tetanus, but more research is needed to confirm this 4