Pharmacology
Immunoglobulins and Vaccines
You are leading a teaching session on tetanus prophylaxis. Regarding management of a tetanus-prone wound which of the following statements is CORRECT:
Answer:
Tetanus vaccine should be injected at a different site from immunoglobulin so that it is not 'neutralised' by the passive immunisation. Management of a tetanus-prone wound depends upon immunisation status as shown in the table below, but may include treatment with tetanus immunoglobulin, tetanus vaccine and antibacterial prophylaxis in addition to wound cleansing.Management of Tetanus-Prone Wounds
Pharmacology / Immunoglobulins and Vaccines
Last Updated: 12th January 2026
Tetanus is an acute disease caused by the action of the tetanus neurotoxin (tetanospasmin) produced by the bacterium Clostridium tetani, an anaerobic spore forming bacillus. Tetanus spores are widespread in the environment, including in soil and manure. They can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through a puncture wound but also through trivial, unnoticed wounds, through injecting drug use, and occasionally through abdominal surgery. The bacteria grow anaerobically at the site of the injury and have an incubation period of between four and 21 days (most commonly about ten days).
Definition of tetanus-prone wounds
Clean wounds are defined as:
- wounds less than 6 hours old, non-penetrating with negligible tissue damage
Tetanus-prone wounds include:
- puncture-type injuries acquired in a contaminated environment and likely therefore to contain tetanus spores e.g. gardening injuries
- wounds containing foreign bodies
- compound fractures
- wounds or burns with systemic sepsis
- certain animal bites and scratches - although smaller bites from domestic pets are generally puncture injuries animal saliva should not contain tetanus spores unless the animal has been routing in soil or lives in an agricultural setting
High risk tetanus-prone wounds are any of the above with either:
- heavy contamination with material likely to contain tetanus spores e.g. soil, manure
- wounds or burns that show extensive devitalised tissue
- wounds or burns that require surgical intervention that is delayed for more than six hours are high risk even if the contamination was not initially heavy
Management of tetanus-prone wounds
Thorough cleaning of wounds is essential and surgical debridement of devitalised tissue in high risk tetanus–prone wounds is crucial for prevention of tetanus. If the wound, burn or injury fulfils the above criteria, IM-TIG or HNIG should be given to neutralise toxin. A reinforcing dose of tetanus-containing vaccine should also be considered based on the immunisation status. Consider treating tetanus prone wounds with antibiotics (metronidazole, benzylpenicillin or co-amoxiclav) depending on clinical severity with a view to preventing tetanus.
Determination of vaccination status may not be possible at the time of assessment and therefore a number of Point of Care antibody (POC Ab) have been developed. There is currently a lack of evidence on use of point of care antibody testing in the clinical pathway, and this it is currently not recommended for use in assessment of tetanus-prone wounds or diagnosis of suspected tetanus by the WHO. Determination of vaccination status using vaccination records remains the preferred method.
| Immunisation Status | Clean Wound | Tetanus Prone Wound | High Risk Tetanus Prone Wound |
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Important considerations:
- An adequate priming course is defined as at least 3 doses of tetanus vaccine at appropriate intervals. N.B. This definition of “adequate course” is for the risk assessment of tetanus-prone wounds only. The full UK schedule is five doses of tetanus containing vaccine.
- The dose of human tetanus immunoglobulin (IM-TIG) is normally 250 IU by intramuscular injection, or 500 IU if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns. The dose is the same for both adults and children.
- In the absence of IM-TIG, the human normal immunoglobulin (HNIG) product Subgam 16% can be used instead.
- Tetanus vaccine should be injected at a different site from immunoglobulin so that it is not 'neutralised' by the passive immunisation.
- Patients who are severely immunosuppressed may not be adequately protected against tetanus, despite having been fully immunised, and additional booster doses or treatment may be required.
- For those whose immunisation status is uncertain, and individuals born before 1961 who may not have been immunised in infancy, a full course of immunisation is likely to be required.
- For those who are incompletely immunised, further doses should be offered to complete the recommended schedule to protect against future exposures.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
