Tetanus prophylaxis

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Tetanus-prone wounds:

• Any wound or burn sustained more than 6 hours
• Any wound or burn at any interval after injury that shows one or more of 
  • significant degree of devitalised tissue
  • puncture-type wound
  • contact with soil or manure likely to harbour tetanus organisms
  • clinical evidence of sepsis

Thorough surgical toilet of the wound is essential irrespective of patients tetanus status

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Indications for use of anti-tetanus immunoglobulin;

1. Those with tetanus-prone wounds who have not received at least 3 doses of tetanus toxoid and their last dose within 10 years.
2. Patients with impaired immunity who suffer a tetanus-prone wound – may in addition require anti-tetanus immunoglobulin.
3. Patients who have suffered a high-risk wound, regardless of vaccine history ^{Ref 3}.

 

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Anti-tetanus prophylaxis

Immunisation status	Clean wound	Tetanus prone wound (definition above)
Data compiled by Dr Íomhar O' Sulivan
	Vaccine	Vaccine	Tetanus immunoglobulin
Fully immunised i.e. has received a total of 5 doses of vaccine at appropriate intervals as single antigen or in a combined vaccine	None required	None required	Only if risk is especially high (e.g. contaminated with stable manure)
Primary immunisation incomplete or boosters not up to date	A reinforcing dose of combined tetanus/diphtheria vaccine and to see GP for further doses as required to complete the recommended schedule (to ensure future immunity)	A reinforcing dose of combined tetanus/diphtheria vaccine and to see GP for further doses as required to complete the recommended schedule (to ensure future immunity)	Yes: one dose of human tetanus immunoglobulin in a different site
Not immunised or immunisation status not known or uncertain	An immediate dose of vaccine and to see GP for completion of a full 3 dose course of combined tetanus/diphtheria vaccine to ensure future immunity	An immediate dose of vaccine and to see GP for completion of a full 3 dose course of combined tetanus/diphtheria vaccine to ensure future immunity	Yes: one dose of human tetanus immunoglobulin in a different site

However trivial the wound, ask about the patient's immune state and offer booster doses to those patients who are not up-to-date and encourage non-immunised people to have a full course.

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Risk assessment of wounds for use of tetanus immunoglobulin (TIG)

Table 2: Risk assessment of wounds for use of tetanus immunoglobulin (TIG) ^{Ref 3}

Age	Immunisation status	Clean wound	Tetanus prone wound
<4 years	<3 doses or unknown   3 or more doses	DTaP/IPV+/-Hib(2)   Nil	TIG, DTaP/IPV +/- Hib Ref 3   Nil, Consider TIG Ref 1
>4 to 9 years	<3 doses or unknown   3 doses only, >5 years since last dose   3 or more doses, <5 years since last tetanus toxoid   4 or more doses, >5 years since last dose	DTaP/IPV   DTaP/IPV   Nil   Nil	TIG plus DTaP/IPV   DTaP/IPV, Consider TIG Ref 1   Nil, Consider TIGRef 1   DTaP/IPV, consider TIGRef 1
10 years and over	<3 doses or unknown   3 or more doses >10 years since last dose   3 or more doses, <10 years since last dose	Td   Td   Nil	TIG plus Td/IPV   Td, consider TIGRef 1   Consider TIGRef 1

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Prophylactic Adult dose of tetanus immunoglobulin

250 iu IM            standard dose

500 iu IM           if > 24 hours since injury, patient >90kg or heavily contaminated wound or burn wound or open fracture wound

 

Therapeutic dose of tetanus immunoglobilin (established tetanus)

• 150 IU/kg IM (given in multiple sites ^{Ref 1)}
• If a large volume (>2ml for children) is required, it is recommended to administer this in divided doses at different sites.

When simultaneous vaccination and immunoglobulin are needed they should be administered at two different sites.

• For prophylaxis, if intramuscular administration is contra-indicated (coagulation bleeding disorders), the injection can be administered subcutaneously. However, it should be noted that there are no clinical efficacy data to support administration by the subcutaneous route ^{Ref 4}

Please Note: Tetanus immunoglobulin should not be administered IV (anaphylaxis risk) ^{Ref 4}

 

Note

• Patients born before 1961 may not have been immunised
• Immunocompromised patients may not respond to vaccination & may need immunoglobulin
• In the absence of other contraindications, immunocompromised and HIV+ patients can be given tetanus vaccine

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References

1. BNF for children 2008. Section 14.5 Immunoglobulins.

2. Medicines for children 2003. Published by the Royal College of Paediatrics and Child Health.

3. Immunisation Guidelines for Ireland. National Immunisation Advisory Committee. 2008 Edition. Chapter 15,Tetanus.

4. Summary of Product Characteristics for Tetabulin S/D 250IU/ml Solution for Injection. Revised April 2006.

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Content by Dr Íomhar O' Sullivan 23/06/2002.  Reviewed by Dr ÍOS 10/07/2004, 12/07/2005, 08/02/2007. Reviewed and update by Stephanie Mulcair, CNM2, Immunisation, CUH and byTricia Collier (Pharmacist CUH) 12/12/2008. Next review 12/12/2009.