CHAPTER 21

Tetanus Immunity
and Antibiotic Wound
Prophylaxis
Key Practice Points
nn All

patients with abrasions, lacerations, burns, or other wounds require

a tetanus immunization history.
nn Tetanus occurs almost exclusively in patients with incomplete primary
immunization.
nn Tetanus prophylaxis for wounds provides an opportunity to boost
immunity for pertussis and diphtheria with Tdap (combined tetanus,
diphtheria, and pertussis) vaccines.
nn Tetanus immune globulin (TIG) can be administered to patients with a
true allergy to tetanus toxoid or patients who have not completed primary
immunization, but TIG does not confer immunity for future wounds.
nn Local pain and swelling are the most common reactions to tetanus
prophylaxis, either Td or Tdap.
nn Uncomplicated lacerations in otherwise healthy patients usually do not
need prophylactic antibiotics.
nn Although there is no clear scientific evidence, prophylactic antibiotics
are recommended for complicated wounds, mammalian bites, impaired
host defenses, and so forth (see text).
nn Antibiotics should be started at the time of wound care to maximize
their effect.
nn In recent years, community-acquired methicllin-resistant Staphylococcus
aureus (CA-MRSA) has become an important cause of wound infection.

Two issues of prophylaxis arise for virtually all patients with wounds and lacerations.
A careful history is taken to establish the tetanus immune status of every patient.
Although nurses in most emergency departments (EDs) are required to document
immune status in their notes, the ultimate responsibility lies with the physician to
ensure that the patients tetanus prophylaxis is up to date.
Far more controversial and problematic is the issue of antibiotic prophylaxis. Despite
the fact that 90% to 95% of all patients with uncomplicated lacerations do not acquire
an infection, there remains an excessive use of prophylactic antibiotics.1-5 As discussed
subsequently, multiple large studies have failed to support the use of prophylactic antibiotics, and they may increase the risk for infection.

TETANUS PROPHYLAXIS
For all patients with an emergency wound or laceration, a decision has to be made
about whether to administer tetanus prophylaxis. Although contaminated wounds
with extensive devitalized tissue are considered more tetanus-prone than are clean
282
Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

Chapter 21 Tetanus Immunity and Antibiotic Wound Prophylaxis

minor wounds, one third of documented cases of tetanus have originated from seemingly trivial injuries.6,7 A common portal of entry for tetanus is a puncture wound to
the foot.7 The importance of tetanus prophylaxis was underscored during a shortage
of immunization doses in 2001.8 During this period, the number of cases of tetanus
increased.9
Despite widespread immunization programs, 40 to 50 cases of tetanus are reported
each year. Tetanus occurs almost exclusively in patients who have never been immunized or who have never completed a proper immunization program.10 Probably for
this reason, most cases are reported in patients who are older than age 50.10 A high
proportion of older adults, when tested for serum tetanus antibody, have been shown
to have inadequate levels of protection.11,12 Young adults and children are more likely
to have appropriate levels of protection because of widespread immunization programs that have been put into place in recent years. Regardless of the circumstances, a
careful immunization history is taken for every patient with a minor wound. This history should establish whether initial immunization has been properly completed and
should establish the date of the last tetanus toxoid dose.

Immunization Schedules

When patients present for wound care, the opportunity is taken to boost immunity
to diphtheria and pertussis as well as tetanus. Diphtheria, although rare, still occurs,
and a diphtheria toxoid booster will help maintain immunity.13 Pertussis is more
common, with 25,000 cases reported in 2005.14 In 2005, a tetanus toxoid, reduced
diphtheria toxoid, and acellular pertussis vaccine (Tdap) was approved for use in
adults from ages 11 to 64 years.13 DTaP, which contains a higher concentration of
diphtheria and pertussis than Tdap, continues to be the primary vaccination agent
for children. In 2010 the Advisory Committee in Immunization Practices (ACIP) of
the Centers for Disease Control and Prevention recommended that Tdap could be
safely given to children from ages 7 to 10 and for adults >64 years old.15 Tdap is
particularly important for patients <64 if they will have contact with children aged
12 months or less. These updated recommendations are reflected in Figure 21-1.
The standard interval between doses of tetanus booster is 10 years. In regions with
increased risk for pertussis, this interval can be as little as 5 years (2 years in Canada),
if the patient has never received a Tdap as an adult. Thereafter, Td is given at 10-year
intervals.13 The ACIP recommends Td for pregnant women because of the lack of
safety data for Tdap in pregnancy.16 However, if protection from pertussis is considered important, Tdap can be administered as long as the patient is made aware of the
lack of that safety data.16

Complications of Tetanus Toxoid and Tdap

Occasionally a patient reports an allergic reaction to a previously administered tetanus

shot. In a study of 740 patients who claimed to be allergic to tetanus shots, the true incidence of allergy on skin challenge testing was low.17 Of the 740 patients, 7 developed
local reactions that were self-limited. One patient became syncopal, and one developed
a fever that lasted for 4 days. Only 1 of 740 patients had a true urticarial response but
still tolerated a full immunizing dose. Despite these reassuring figures, the possibility
of a serious reaction still must be considered.17 For patients considered at high risk
for a reaction, tetanus immune globulin (250 to 500 U) is provided in the ED. Tetanus
immune globulin confers immunity for that injury but not for future exposures. This
preparation consists only of antitetanus antibody and does not cross-react with the toxoid. Referral to an allergist for skin testing and subsequent immunization with toxoid
is recommended as prudent follow-up.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

283

284

Chapter 21 Tetanus Immunity and Antibiotic Wound Prophylaxis

ASSESS WOUND

A clean, minor wound

All other wounds

(contaminated with dirt, feces, saliva,
soil; puncture wounds; avulsions;
wounds resulting from flying or crushing
objects, animal bites, burns, frostbite)

Has patient completed

a primary tetanus
diphtheria series?1,7

Has patient completed

a primary tetanus
diphtheria series?1,7

No/Unknown

Yes

No/Unknown

Yes

Administer vaccine
today. 2,3,4
Instruct patient to
complete series
per age-appropriate
vaccine schedule.

Was the most

recent dose within
the past 10 years?

Administer vaccine
and tetanus immune
globulin (TIG)
now.2,4,5,6,7

Was the most

recent dose within
the past 5 years?7

No

Yes

No

Yes

Administer
vaccine today.2,4
Patient should receive
next dose per
age-appropriate
schedule.

Vaccine not
needed today.
Patient should
receive next dose
at 10-year interval
after last dose.

Administer
vaccine today.2,4
Patient should receive
next dose per
age-appropriate
schedule.

Vaccine not
needed today.
Patient should
receive next
dose at 10-year
interval after
last dose.

Figure 21-1. Summary guide to tetanus prophylaxis in routine wound management. 1, A primary series
consists of a minimum of three doses of tetanus- and diphtheria-containing vaccine (DTaP/DTP/Tdap/DT/
Td). 2, Age-appropriate vaccine: DTaP for infants and children from 6 weeks through 6 years of age (or DT
pediatric if pertussis vaccine is contraindicated); Tdap for persons 7 through 10 years of age if they have not
completed vaccination with DTaP; Tdap for persons >64 years of age if they have not previously received
Tdapotherwise, Td can be administered; and Tdap for persons 11 through 64 years of age, unless they have
received Tdap previously. 3, No vaccine or TIG is recommended for infants <6 weeks of age with clean minor
wounds (and no vaccine is licensed for infants <6 weeks of age). 4, Tdap is preferred for persons 10 through
64 years of age who have never received Tdap. Td is preferred over tetanus toxoid (TT) for persons 7 through
10 years of age or >64 years of age or for those who have previously received Tdap. If TT is administered,
an adsorbed TT product is preferred to fluid TT. (All DTaP/DTP/Tdap/DT/Td products contain adsorbed
tetanus toxoid.) 5, Provide TIG 250 U for all ages. It can and should be administered simultaneously with
tetanus-containing vaccine. 6, For infants <6 weeks of age, TIG (without vaccine) is recommended for dirty
wounds (wounds other than clean, minor). 7, Persons who are HIV positive should receive TIG regardless
of tetanus immunization history. (Modified with recommendations from Centers for Disease Control and
Prevention: Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acelleular
pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010, MMWR Morb
Mortal Wkly Rep 60:1315, 2011.)

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

Chapter 21 Tetanus Immunity and Antibiotic Wound Prophylaxis

Local and systemic reactions to Td are uncommon but occur in 7% to 9% of pediatric

patients.18 Pain, swelling, and erythema can occur at the injection site, but these reactions usually are self-limited. When Tdap and Td are compared, the safety and adverse
event profiles are similar to one another.13 Common local symptoms include pain at
the injection site, erythema, and swelling. Systemic symptoms observed in both Tdap
and Td are headache, body aches, fatigue, and nausea. No cases of Guillain-Barr were
observed in the safety studies.13

PROPHYLACTIC ANTIBIOTICS
FOR EMERGENCY WOUNDS
For small, uncomplicated, minor, nonbite wounds and lacerations, there is no convincing clinical evidence that systemic antibiotics provide protection against the development of wound infection.5,19-21 A randomized, controlled study using oral cephalexin
for prophylaxis showed no efficacy of the antibiotic for minor lacerations.5 In two
randomized, controlled studies using oral or parenteral cephalosporins for minor
hand lacerations, there was no increase in the infection rate of nonantibiotic-treated
patients compared with patients treated with antibiotics.1,19,20
In a study of 2834 pediatric patients, not only was there no protective effect, but there
also was a significant increase in the infection rate in the antibiotic-treated patients.22
Other studies also support this contradiction.3,5,20,23 It is thought that selection for
resistant organisms, rebound bacterial proliferation after the initial effect, or impairment of host defenses by the drugs might account for this paradox.
Although not all authorities agree, and there is no strong scientific evidence underlying any specific set of recommendations for wound antibiotic prophylaxis, clinical
and empirical experiences suggest that there are wound characteristics and circumstances that warrant antibiotic intervention.24-26 If antibiotics are indicated, there is
some evidence that the initial dose has to be administered as soon as possible to obtain
an effect.23,25,26 Delays in treatment beyond 3 to 5 hours from injury have been shown
in some studies to lead to an increase in the infection rate.24 Other investigators have
found little correlation between the interval between injury and antibiotic delivery and
the ultimate risk of wound infection.
The following are guidelines for when antibiotics should be considered:
Wound age: Relative indications include hand and foot wounds more than 8 hours
old, facial wounds more than 24 hours old, and wounds at other sites more than 12
hours old.
Wound condition: Crushing mechanism wounds for which extensive dbridement and
tissue revision are needed.
Contamination: Wounds initially contaminated with soil, vegetative matter, and other
particulates that require extensive cleaning and irrigation.
Suspected CA-MRSA contamination: Risk factors for CA-MRSA include HIV, previous
or current incarceration, previous MRSA infection, athletes, veterinarians, indigents,
and children.
Mammalian bites: See Chapter 15 for indications regarding wound prophylaxis in dog,
cat, and human bites.
Vulnerable anatomic sites: Wounds of cartilage (ear, nose), tendon, bone, and joint.
Circulatory impairment: Wounds in impaired areas of drainage, such as lymphedema
secondary to venous disease or surgical procedure (radical mastectomy).
Impaired host defenses: Diabetes, immunosuppressive agents (corticosteroids, anti
cancer agents), and diseases with altered immune status.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

285

286

Chapter 21 Tetanus Immunity and Antibiotic Wound Prophylaxis

Cardiac valvular disease:

Guidelines published by the American Heart Association

should be followed relative to wounds in patients with cardiac valvular disease. Prophylaxis is not indicated in patients who have clean, uncomplicated lacerations.
Orthopedic implants: Prophylaxis should be considered in patients with orthopedic
implants who have contaminated wounds. Prophylaxis is not indicated for clean,
uncomplicated wounds.

ANTIBIOTIC CHOICES
The choice of antibiotics for nonbite wound prophylaxis is based on the likely infecting
organisms. Multiple studies have shown that for common, uncomplicated wounds and
lacerations, S. aureus and Streptococcus species have been the most common infecting
agents in more than 90% of cases.20,21,23,27 In recent years, there has been an explosion of
CA-MRSA cases.28 More extensive wounds, involving contamination with soil, increase
the spectrum to include gram-negative organisms and Clostridium species.29 Wounds
involving fresh water, including lakes, streams, and swimming pools, may be contaminated with Aeromonas hydrophila.30,31 Injuries occurring in salt water can be infected
with Vibrio vulnificus.32
For prophylaxis to be effective, the initial dose should be delivered as soon after the
injury as possible, preferably in parenteral form, to ensure an adequate level of antibiotic activity.25,26,33,34 For a common, uncomplicated, nonbite wound requiring
prophylaxis, the first-generation cephalosporin cefazolin (Ancef) can be administered parenterally, followed by a 3- to 5-day course of cephalexin (Keflex), cephradine
(Velosef), cefadroxil (Duricef), or dicloxacillin. Cefadroxil has the advantage of oncea-day or twice-a-day dosing, which may encourage greater compliance.
For patients allergic to penicillin and cephalosporins, an intravenous dose of clindamycin (Cleocin) followed with oral clindamycin provides coverage of common infecting organisms. Because of the short course, the risk of diarrheal complications from
clindamycin is negligible. The macrolides, including erythromycin and azithromycin,
are another alternative.
If CA-MRSA is suspected, trimethoprim/sulfamethoxazole (TMP-SMX), clindamycin,
or doxycycline can be used prophylactically.
When the offending organism cannot be determined clinically, the combination of
TMP-SMX with cefalexin will provide coverage for CA-MRSA, methicillin-sensitive
S. aureus, and group A Streptococcus. Clindamycin is an alternative.
If A. hydrophila is suspected, ciprofloxacin (Cipro), TMP/SMX (Bactrim, Septra), or an
aminoglycoside provides adequate coverage. V. vulnificus is more difficult to treat but
is sensitive to doxycycline (Vibramycin), chloramphenicol, and ceftazidime (Fortaz).

References

1. Cummings P, Del Beccarro MA: Antibiotics to prevent infection of simple wounds: a meta-analysis of
randomized studies, Am J Emerg Med 13:396400, 1995.
2. Gosnold JK: Infection rate of sutured wounds, Practitioner 218:584585, 1977.
3. Hutton PA, Jones BM, Law DJ: Depot penicillin as prophylaxis in accidental wounds, Br J Surg 65:
549550, 1978.
4. Rutherford WH, Spence R: Infection in wounds sutured in the accident and emergency department, Ann
Emerg Med 9:350352, 1980.
5. Thirlby RC, Blair AJ, Thal ER: The value of prophylactic antibiotics for simple lacerations, Surg Gynecol
Obstet 156:212216, 1983.
6. Brand DA, Acampora D, Gottleib LD, etal: Adequacy of anti-tetanus prophylaxis in six hospital emergency departments, N Engl J Med 309:636640, 1983.
7. Furste W: Fifth international conference on tetanus, Ronneby, Sweden, 1978, J Trauma 20:101105, 1980.
8. Zun LS, Downey L: Tetanus immunization shortage in the US, Am J Emerg Med 21:298301, 2003.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

Chapter 21 Tetanus Immunity and Antibiotic Wound Prophylaxis

9. Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillanceUnited States, 1998-2000, MMWR
Morb Mortal Wkly Rep Surveill Summ 52(SS03):18, 2003.
10. Richardson JP, Knight AL: The management and prevention of tetanus, J Emerg Med 11:737742, 1993.
11. Alagappan K, Rennie WP, McPherson P, etal: Seroprevalence of antibody levels to tetanus in adults over
65 years of age (abstract), Acad Emerg Med 2:373, 1995.
12. Crossley K, Irvine P, Warren JB, et al: Tetanus and diphtheria immunity in urban Minnesota adults,
JAMA 242:22982300, 1983.
13. Kretsinger K, Boder RK, Cortese MM: Preventing tetanus, diphtheria, and pertussis among adults:
use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, MMWR Recomm Rep
55(RR17):133, 2006.
14. CDC: Final 2005 reports of notifiable diseases, MMWR 55:880881, 2005.
15. CDC: Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular
pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010, MMWR Morb
Mortal Wkly Rep 60(01):1315, 2011.
16. Appendix A: summary of ACIP recommendations for prevention of pertussis, tetanus, and diphtheria
among pregnant and postpartum women and their infants, MMWR Recomm Rep 57(04):4949, 2008.
17. Jacobs RL, Lowe RS, Lanier BQ: Adverse reactions to tetanus toxoid, JAMA 247:4042, 1982.
18. Cody CL, Baraff LJ, Cherry JD, etal: Nature of adverse reactions associated with DTP and DT immunizations in infants and children, Pediatrics 68:650660, 1981.
19. Grossman JA, Adams JP, Kunec J: Prophylactic antibiotics in simple hand lacerations, JAMA 245:
10551056, 1981.
20. Haughey RE, Lammers RL, Wagner DK: Use of antibiotics in the initial management of soft tissue
wounds, Ann Emerg Med 10:187190, 1981.
21. Samson RH, Altman SF: Antibiotic prophylaxis for minor lacerations, N Y State J Med 77:17281730,
1977.
22. Baker MD, Lanuti M: The management and outcome of lacerations in urban children, Ann Emerg Med
19:10011005, 1990.
23. Worlock P, Boland P, Darrell J, etal: The role of prophylactic antibiotics following hand surgery, Br J Clin
Pract 34:290292, 1980.
24. Burke JF: The effective period of preventive antibiotic action in experimental incisions and dermal
lesions, Surgery 50:161168, 1961.
25. Cardany CR, Rodeheaver G, Thacker J, et al: The crush injury: the high risk wound, J Am Coll Emerg
Physicians 5:965970, 1976.
26. Edlich RF, Kenny JG, Morgan RF, etal: Antimicrobial treatment of minor soft tissue lacerations: a critical
review, Emerg Clin North Am 4:561580, 1986.
27. Day TK: Controlled trial of antibiotics in minor wounds requiring suture, Lancet 2:11741176, 1975.
28. David MZ, Daum RS: Community-associated methicillin-resistant Staphylococcus aureus: epidemiology
and clinical consequences of an emerging epidemic, Clin Microbiol Rev 23:616687, 2010.
29. Fitzgerald RH, Cooney WP, Washington JA, etal: Bacterial colonization of mutilating hand injuries and
its treatment, J Hand Surg 2:8589, 1977.
30. Gold WL, Salit IE: Aeromonas hydrophila infections of the skin and soft tissue: report of 11 cases, Clin
Infect Dis 16:6974, 1993.
31. Skiendzielewski WH, OKeefe KP: Wound infection due to fresh water contamination of, Aeromonas
hydrophila, J Emerg Med 8:701703, 1990.
32. Chuang YC, Young C, Chen CW: Vibrio vulnificus infection, Scand J Infect Dis 21:721726, 1989.
33. Morgan WJ, Hutchinson D, Johnson HM: The delayed treatment of wounds of the hand and forearm
under antibiotic cover, Br J Surg 67:140141, 1976.
34. Edlich RF, Rodeheaver GT, Thacker JG, etal: Revolutionary advances in the management of traumatic
wounds in the emergency department during the last 40 years: part 1, J Emerg Med 20:111, 2009.

Downloaded from ClinicalKey.com at Univ Targu Mures Med Pharmacy March 30, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

287