10/30/2018 Tetanus Prophylaxis

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Tetanus Prophylaxis
Tetanus prone

Indications prophylaxis

Tetabulin

References

Tetanus-prone wounds: In the Mx of tetanus-prone wounds,

tetanus immunoglobulin of human origin
Any wound or burn sustained more (‘HTIG’) should be used in addition to
than 6 hours. wound cleansing and, where appropriate,
Any wound or burn at any interval antibacterial prophylaxis and a tetanus-
after injury that shows one or more of containing vaccine. The preparation of
significant degree of devitalised tetanus immunoglobulin currently
tissue. available from the pharmacy in CUH is
puncture-type wound. Tetabulin ®.
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.

Indications for use of anti- A pre-filled syringe of Tetabulin 250IU

(1ml) contains:
tetanus immunoglobulin;
Human tetanus immunoglobulin
1. Those with tetanus-prone wounds 250IU
who have not received at least 3 Human protein 100 – 170mg (of
doses of tetanus toxoid and their which at least 90% are immunoglobulin
last dose within 10 years.
G) Ref 2.
2. Patients with impaired immunity
who suffer a tetanus-prone wound
– may in addition require anti-
tetanus immunoglobulin.
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10/30/2018 Tetanus Prophylaxis

3. Patients who have suffered a high-

risk wound, regardless of vaccine
history Ref 3.

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

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10/30/2018 Tetanus Prophylaxis

<4 years <3 doses or unknown 3 or more doses 6 in 1 vaccine Nil TIG + 6 invaccine Nil, Consider
TIG Ref 1
<3 doses or unknown 6 in 1 or 4 in 1 TIG + 6 in 1 or 4 in 1 vaccine
vaccine
3 doses only, ≥5 years since last dose 4 in 1 vaccine 4 in 1 vaccine
Consider TIG*
>4 to 9 years
3 or more doses, <5 years since last Nil 4 in 1 vaccine
tetanus toxoid Consider TIG*
4 or more doses, >5 years since last Nil Consider TIG*
dose
<3 doses or unknown Td, Tdap or TIG + Td, Tdap or Tdap/IPV
Tdasp/IPV
3 or more doses >10 years since last Td or Tdap Td or Tdap
10 years and dose Consider TIG*
over 3 or more doses, <10 years since last Nil Consider TIG*
dose
*Consider TIGfor fully vaccinated patients TIG = Tetanus Immunoglobulin
with: DTaP/IPV/Hib = Diphtheria, Tetanus
and acellular Pertussis vaccine/Inactivated
impaired immunity including those
with diabetes, immunosuppressive Polio Virus vaccine/ Haemophilius
conditions and IV drug abuse. influenzae b vaccine
a wound contaminated with stable DTaP/IPV = Diphtheria, Tetanus and
manure, or extensive devitalised tissue acellular Pertussis vaccine/Inactivated
regardless of vaccine status. Polio Virus vaccine
HIV positive 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

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
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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

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 11/04/18

© Cork Emergency Medicine 2018 Dr ÍOS

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