An 11-year-old boy presents to the emergency department with his parents 1 hour after stepping on a rusty nail with his bare foot. He received his 5th dose of DTaP vaccine at age five and has not yet received his first dose of Tdap. He is otherwise up to date on his vaccinations and has no chronic conditions. His vital signs are notable for mild tachycardia, and physical examination is notable for a 0.5 centimeter punctate lesion on his right heel that is oozing blood. There is significant dirt in and around the wound.
In addition to wound irrigation, which of the following is the next best step in management?
A) Administer a tetanus toxoid-containing vaccine
This individual has a dirty wound and ≥ 3 lifetime doses of tetanus toxoid vaccination but is ≥ 5 years from his most recent dose, so a tetanus toxoid-containing vaccine is indicated.
Answer choice B: Administer a tetanus toxoid-containing vaccine and human tetanus immune globulin, is incorrect. This is the treatment for wounds that are not clean/minor in individuals with < 3 lifetime doses of tetanus toxoid vaccines or unknown vaccination history. This individual has a known vaccination history with ≥ 3 lifetime doses of tetanus toxoid-containing vaccines.
Answer choice C: Administer human tetanus immune globulin, is incorrect. Tetanus immune globulin is not given in isolation; it is always given with a tetanus toxoid-containing vaccine.
Answer choice D: No additional action, is incorrect. This patient is greater than 5 years from his most recent dose of tetanus toxoid-containing vaccination and has a dirty wound. He therefore requires a booster with a tetanus toxoid-containing vaccine.
Answer choice E: Prescribe levofloxacin, is incorrect. Although levofloxacin does provide coverage for Pseudomonas aeruginosa (common in plantar puncture wounds), antibiotic prophylaxis is not indicated in this otherwise healthy child without risk factors for infection (e.g., diabetes mellitus, immunocompromised, injury through an intact shoe). Though levofloxacin and ciprofloxacin cover Pseudomonas aeruginosa and can be given orally, the use of fluoroquinolones in children has been restricted due to potential cartilage damage that occurred in research with immature animals.
Key Learning Point
In the setting of possible tetanus exposure, individuals with ≥ 3 lifetime doses of tetanus toxoid vaccination require additional vaccination if (1) their last vaccination was ≥ 10 years ago and the wound is clean/minor, or (2) their last vaccination was ≥ 5 years ago and the wound is not clean/minor. All individuals with < 3 lifetime doses of tetanus toxoid vaccination require additional vaccination and should also receive human tetanus immune globulin if the wound is not clean/minor.
