Immunizations

With any laceration or open skin injury, tetanus immunizations should be updated if indicated. If patients have received 3 or more primary tetanus immunizations, they should receive an update if their last immunization was more than 10 years ago for a clean wound and if more than 5 years ago with a dirty wound. Patients should receive tetanus immune globulin (TIG) and begin their tetanus immunization series if they have had less then 3 immunizations in the past. Diphtheria toxoid and pertussis antigens with tetanus toxoid (Tdap) should replace a single dose of Td for adults age 19 through 64 years who have not received a dose of Tdap previously and require a booster. Tdap may be given as close as 2 years after a Td. Td can be given every 10 years when needed after one Tdap is received (CDC, 2009; see Web Resources).

Patients should begin the hepatitis B immunization series for any human bite wounds or for mucus membrane blood exposure. Patients should be offered and consented for baseline testing for hepatitis B virus (HBV) and C virus (HCV) and human immunodeficiency virus (HIV). Appropriate follow-up based on test results must be arranged. HBIG is indicated if the patient has injuries from a person known to be positive for hepatitis B surface antigen (HBsAg); however, needle stick guidelines suggest that the injured patient receive only a hepatitis B immunization series and not HBIG if the contact person has an unknown or negative carrier status. In the case of a needle stick, HIV prophylaxis with three drugs is recommended if the contact person is a known HIV positive. If the source patient has an unknown HIV status, postexposure prophylaxis (PEP) generally is not indicated, unless there is concern that the source is higher risk, in which case two-drug PEP is offered.

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