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 (option A). Since the patient has been previously immunized but the last dose was more than 10 years ago, a booster dose of tetanus toxoid is indicated, as recommended by the Centers for Disease Control and Prevention 1. The key points to consider in this scenario include:

• The patient's previous immunization status and the time elapsed since the last dose
• The type of wound and its potential for contamination
• The current guidelines for tetanus prophylaxis in wound management According to the most recent guidelines from 2018 1, a tetanus toxoid–containing vaccine is indicated as part of wound management if more than five years has passed since the last tetanus toxoid–containing vaccine dose. In this case, the patient's immunity has likely waned somewhat after 12 years, but they still have baseline protection from their previous vaccination series. The tetanus toxoid booster will rapidly stimulate the immune system to produce protective antibodies against tetanus. Tetanus immunoglobulin is not necessary for previously vaccinated individuals unless the wound is heavily contaminated or there are signs of infection. The combination of tetanus toxoid and immunoglobulin is typically reserved for patients with no prior immunization or uncertain vaccination status with contaminated wounds. Antiserum toxin is an outdated term and not used in modern tetanus prevention protocols. Given the patient's history and the current guidelines, administering tetanus toxoid (option A) is the most appropriate course of action to prevent tetanus infection and ensure the patient's safety, as supported by the recommendations of the Advisory Committee on Immunization Practices (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 † 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): Yes, as an adjunct to Td for wound management.

Therefore, the best option is C. Tetanus toxoid + Immunoglobulin 2.

From the Research

Tetanus Prophylaxis for Hand Injury

• The patient has a hand injury from a barbed wire and received anti-tetanus vaccine 12 years ago.
• The best course of action would be to administer a booster dose of tetanus toxoid, as the patient's last dose was more than 10 years ago 3.
• According to the study, the formation of tetanus antibody after tetanus vaccination is not influenced by tetanus immunoglobulin (TIG) at the late period and in adults below the age of 50 yr 3.
• However, the study also suggests that there are significant differences between the two groups at the early period of 4 weeks after vaccination and for patients over 60 yr 3.
• Another study discusses the production of monoclonal antibodies against tetanus toxin and toxoid, which could be used for detection and prevention of tetanus 4.
• A more recent study developed a fluorescent tetanus human IgG-AuNC-based immunochromatography test strip for detecting tetanus toxoid, which could be useful in safety testing of tetanus vaccine 5.
• For hand injuries, proper assessment and management can reduce morbidity and prevent long-term disability, and tetanus prophylaxis is an important aspect of this management 6.

Recommended Course of Action

• Administer a booster dose of tetanus toxoid (option A) to ensure the patient has adequate protection against tetanus.
• This is because the patient's last dose was more than 10 years ago, and a booster dose is recommended every 10 years 3.