Tetanus prophylaxis



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.

In the Mx of tetanus-prone wounds, tetanus immunoglobulin of human origin (‘HTIG’) should be used in addition to wound cleansing and, where appropriate, antibacterial prophylaxis and a tetanus-containing vaccine. The preparation of tetanus immunoglobulin currently available from the pharmacy in MUH/CUH is Tetagam®.


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.

Tetagam

  • Is a blood product so we are obliged to record patient details.
  • The record (held in the CUH fridge with the tetagam®).
  • Pharmacy fill out the tetagam batch number and expiry.
  • Then when this pre-filled syringe is used, staff administering it are to record the date of admin., affix the patient's addressograph and enter your details.

Anti-tetanus prophylaxis
Immunisation status Clean wound Tetanus prone wound
(definition above)
Data compiled by Dr Íomhar O' Sullivan
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.


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 6 in 1 vaccine Nil TIG + 6 invaccine Nil, Consider TIG Ref 1

>4 to 9 years

<3 doses or unknown 6 in 1 or 4 in 1 vaccine TIG + 6 in 1 or 4 in 1 vaccine
3 doses only, ≥5 years since last dose 4 in 1 vaccine 4 in 1 vaccine
Consider TIG*
3 or more doses, <5 years since last tetanus toxoid Nil 4 in 1 vaccine
Consider TIG*
4 or more doses, >5 years since last dose Nil Consider TIG*

 

10 years and over

<3 doses or unknown Td, Tdap or Tdasp/IPV TIG + Td, Tdap or Tdap/IPV
3 or more doses >10 years since last dose Td or Tdap Td or Tdap
Consider TIG*
3 or more doses, <10 years since last dose Nil Consider TIG*

*Consider TIG (Tetagam®)for fully vaccinated patients with:

  • impaired immunity including those with diabetes, immunosuppressive conditions and IV drug abuse.
  • a wound contaminated with stable manure, or extensive devitalised tissue regardless of vaccine status.
  • HIV positive

TIG = Tetanus Immunoglobulin
DTaP/IPV/Hib = Diphtheria, Tetanus and acellular Pertussis vaccine/Inactivated Polio Virus vaccine/ Haemophilius influenzae b vaccine
DTaP/IPV = Diphtheria, Tetanus and acellular Pertussis vaccine/Inactivated Polio Virus vaccine
Td/IPV = Tetanus, low-dose diphtheria/ Inactivated Polio Virus vaccine
Tdap = Tetanus, low-dose diphtheria and low-dose acellular pertussis vaccine


Prophylactic Adult dose of tetanus immunoglobulin (Tetagam®)

  • 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: Tetagam (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

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.


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. Last review Dr ÍOS 13/05/19