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 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 Advisory Committee on Immunization Practices (ACIP) 1. This will stimulate the immune system to produce protective antibodies against tetanus. Some key points to consider in this scenario include:

• The patient's previous vaccination history and the time elapsed since the last dose
• The nature of the wound, which in this case is a hand injury from barbed wire, potentially contaminated
• The guidelines for tetanus prophylaxis in routine wound management, as outlined in the ACIP recommendations 1 Immunoglobulin alone is not necessary for previously vaccinated individuals with wounds that aren't highly contaminated. The combination of tetanus toxoid and immunoglobulin is reserved for patients who are unvaccinated, incompletely vaccinated, or have uncertain vaccination history with contaminated wounds. Antiserum toxin is an outdated treatment with higher risk of adverse reactions. The tetanus toxoid booster should be administered as soon as possible after the injury to ensure adequate protection against tetanus infection, which can develop from Clostridium tetani spores potentially introduced by the barbed wire, as supported by the most recent and highest quality study available 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 completed it 12 years ago. Given that the patient has sustained a hand injury from a barbed wire, which can be considered a contaminated wound, and it has been more than 10 years since the last dose, the best option would be:

• Tetanus toxoid (to provide active immunity)
• And Tetanus Immune Globulin (TIG) (to provide passive immunity) So the answer is: C. Tetanus toxoid + Immunoglobulin 2 3

From the Research

Tetanus Prophylaxis

The patient has a hand injury from a barbed wire and has not received a tetanus booster in 12 years. Considering the options for tetanus prophylaxis:

• Tetanus Toxoid: The patient's last tetanus toxoid dose was 12 years ago, which is beyond the recommended booster interval of 10 years 4. Administering a tetanus toxoid booster is essential to maintain immunity.
• Immunoglobulin: Tetanus immunoglobulin (TIG) is recommended for individuals with uncertain or incomplete tetanus vaccination history, or for those who have not received a booster dose in the last 5 years 4. However, in this case, the patient has a history of completing the primary series 12 years ago.
• Tetanus Toxoid + Immunoglobulin: This combination is typically recommended for individuals with uncertain or incomplete tetanus vaccination history, or for those who have not received a booster dose in the last 5 years 4.
• Antiserum Toxin: There is no evidence to support the use of antiserum toxin as a first-line treatment for tetanus prophylaxis.

Recommended Approach

Based on the available evidence, the best approach for this patient would be to administer a tetanus toxoid booster dose, as the patient's last dose was 12 years ago 4. Additionally, considering the patient's history of completing the primary series, tetanus immunoglobulin (TIG) may not be necessary, but it could be considered if the patient's wound is particularly dirty or if there is a high risk of tetanus infection 5, 6.

Key Considerations

• The patient's tetanus antibody level may still be protective, despite the time elapsed since the last booster dose 5.
• The immune response to tetanus toxoid may be attenuated in individuals who have already received multiple doses of the vaccine 7.
• The administration of TIG may interfere with the immune response to simultaneous administration of tetanus-diphtheria vaccine, although this effect may be temporary 6.