A 12 year old previously healthy male presents to the ED after stepping barefoot on a broken bottle on the beach. He has a jagged, deep laceration to his Right foot approximately 4cm in length. His immunization history is unknown. What tetanus post-exposure prophylaxis should this patient receive?

A. Tdap AND Tetanus Immunoglobulin

B. Tdap ONLY

C. Td ONLY

D. Neither Tdap or Tetanus Immunoglobulin

E. Tetanus Immunoglobulin ONLY

 

The correct answer is A.

After a “tetanus-prone injury,” it is recommended to receive a tetanus toxoid-containing vaccine (Td, Tdap, TT) if the following conditions are met:

  1. Any person with an uncertain or incomplete history of completing a three-dose primary series of tetanus toxoid-containing vaccine
  2. If the most recent dose was given 10 or more years ago (for minor and clean wounds)
  3. If the most recent dose was given 5 or more years ago (for puncture wounds or wounds contaminated with dirt)

In addition, it is recommended to add a single dose of tetanus immune globulin (except after minor and clean wounds) if it is unclear that the three-dose primary vaccination series has been completed.

 

Because the immunization history in this individual is unknown, he at least would need Tdap or Td. If the wound had been clean and minor, he would not have needed Tetanus Immunoglobulin. However, since this wound is not clean or minor, he would also need Tetanus Immunoglobulin. If the patient had received at least 3 doses of tetanus toxoid-containing vaccines, then he would not require Tdap, DTaP, or Td, or Tetanus Immunoglobulin. However, if the patient has received at least 3 tetanus-containing vaccines, then they would need a booster vaccine without immunoglobulin after 10 years for a clean and minor wound, or after 5 years with all other wounds.

References

  1. Bader MS, McKinsey DS. Postexposure Prophylaxis for Common Infectious Diseases. Am Fam Physician. 2013 Jul 1;88(1):25-32. https://www.aafp.org/afp/2013/0701/p25.html
  2. CDC Immunization Schedule 2020 https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html#note-tdap

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