Wound management and tetanus prophylaxis

Previous doses of tetanus toxoid*	Clean and minor wound		All other wounds^¶
Previous doses of tetanus toxoid*	Tetanus toxoid-containing vaccine^Δ	Human tetanus immune globulin	Tetanus toxoid-containing vaccine^Δ	Human tetanus immune globulin^◊
<3 doses or unknown	Yes^§	No	Yes^§	Yes
≥3 doses	Only if last dose given ≥10 years ago	No	Only if last dose given ≥5 years ago^¥	No

Appropriate tetanus prophylaxis should be administered as soon as possible following a wound but should be given even to patients who present late for medical attention. This is because the incubation period is quite variable; most cases occur within 8 days, but the incubation period can be as short as 3 days or as long as 21 days. For patients who have been vaccinated against tetanus previously but who are not up to date, there is likely to be little benefit in administering human tetanus immune globulin more than 1 week or so after the injury. However, for patients thought to be completely unvaccinated, human tetanus immune globulin should be given up to 21 days following the injury; Td or Tdap should be given concurrently to such patients.

DT: diphtheria-tetanus toxoids adsorbed; DTP/DTwP: diphtheria-tetanus whole-cell pertussis; DTaP: diphtheria-tetanus-acellular pertussis; Td: tetanus-diphtheria toxoids absorbed; Tdap: booster tetanus toxoid-reduced diphtheria toxoid-acellular pertussis; TT: tetanus toxoid.
* Tetanus toxoid may have been administered as DT, DTP/DTwP (no longer available in the United States), DTaP, Td, Tdap, or TT (no longer available in the United States).
¶ Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; or wounds resulting from missiles, crushing, burns, or frostbite.
Δ The preferred vaccine preparation depends upon the age and vaccination history of the patient:

<7 years: DTaP.
Underimmunized children ≥7 and <11 years who have not received Tdap previously: Tdap. Children who receive Tdap at age 7 through 9 years should receive another dose of Tdap at age 11 through 12 years.
≥11 years: A single dose of Tdap is preferred to Td for all individuals in this age group who have not previously received Tdap; otherwise, Td or Tdap can be administered without preference. Pregnant women should receive Tdap during each pregnancy.

◊ 250 units intramuscularly at a different site than tetanus toxoid; intravenous immune globulin should be administered if human tetanus immune globulin is not available. Persons with HIV infection or severe immunodeficiency who have contaminated wounds should also receive human tetanus immune globulin, regardless of their history of tetanus immunization.
§ The vaccine series should be continued through completion as necessary.
¥ Booster doses given more frequently than every 5 years are not needed and can increase adverse effects.

References:

Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2018; 67:1.
Havers FP, Moro PL, Hunter P, et al. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: Updated recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep 2020; 69:77.

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Wound management and tetanus prophylaxis