-
Staphylococcus Aureus
- Facilitated by staphylococcal toxin (TSS Toxin 1 or Enterotoxin B)
- More common in age <40 years
-
Streptococcus Pyogenes (Group A Streptococcus)
- Most common cause of toxic shock and affects all ages
- Facilitated by M Protein (antiphagocytic function), exotoxins and Endotoxins
- S. agalactiae (Group B Strep) and S. Dysgalactiae have also caused Toxic Shock Syndrome
-
Clostridium sordellii (Clostridial Toxic Shock Syndrome)
- Previously associated with elective Termination of Pregnancy (see Unintended Pregnancy)
- Has also occurred with IUD and with IV Drug Abuse
- Often affebrile with high Hemoglobin/hematoctrit and in fatal cases, Leukemoid Reaction (WBC >50k)
- Treated with Penicillins, Carbapenems or Cephalosporins AND Clindamycin
- Requires substantial Fluid Replacement due to capillary leak
- Aldape (2006) Clin Infect Dis 43(11): 1436-46 +PMID:17083018 [PubMed]
- Causes
-
Staphylococcal TSS Precipitating Factors
- Highly absorbent tampons (especially those left in place for days)
- Onset of toxic shock within 5 days of Menses
- Responsible for 50% of Staphylococcal Toxic Shock cases
- Decreasing Incidence in the United States (since highly absorbent tampons are off the market)
- Barrier Contraceptives
- Postoperative Wound Infections (including postpartum), especially wounds that are packed
-
Burn Injury and other Skin Wounds
-
Nasal Packing
-
Osteomyelitis
- Causes
-
Streptococcal TSS Precipitating Factors
-
General
- Pregnancy increases toxic shock risk by 20 fold
- Streptococcal TSS
- Alcoholism
- Diabetes Mellitus
- HIV Infection
- Findings
-
Common Presentations of an Uncommon Disease
- Diffuse Sunburn-like rash with fever and ill appearance
-
Streptococcus or Staphylococcus infection with Sepsis or hemodynamic instability
- Signs of Sepsis with underwhelming infection source findings (e.g. minor Cellulitis, Gastroenteritis)
- Pregnant or postpartum patient following an obstetric procedure
-
Influenza-like illness
- Focal symptoms (depending on source)
-
Nausea or Vomiting
-
Diarrhea
- High Fever
- Rash (Erythroderma)
- Sunburn-like rash that be subtle or transient
-
Hypotension
- Multisystem organ failure (3 or more)
-
Palm and Sole Desquamation
- Late finding, occurring 1-2 weeks after symptom onset
- Evaluate for all possible sources
- Pelvic exam for Retained Foreign Body in all women
-
Chest XRay
- May present in ARDS
- Consider CT imaging of suspected source
-
General Management
- See Septic Shock
- Aggressive supportive care as per Septic Shock regimen
- Rapidly start fluid Resuscitation and Antibiotics
- Staphylococcal Toxic Shock Syndrome Antibiotics
- Methicillin Sensitive (MSSA)
- Nafcillin 2 g IV q4h or Oxacillin 2 g IV q4h (or Cefazolin 1-2 g IV q8h) AND
- Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
- Methicillin Resistant (MRSA)
- Vancomycin (or Daptomycin 6 mg/kg IV q24h or Linezolid) AND
- Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
- Streptococcal Toxic Shock Syndrome Antibiotics
- Early surgical Debridement of Necrotizing Fasciitis
- Primary protocol (preferred)
- Penicillin G AND
- Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
- Alternative protocol (Penicillin Allergy)
- Vancomycin AND
- Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
- Alternative protocol (other)
- Ceftriaxone AND
- Clindamycin 900 mg IV every 8 hours (to suppress toxin production)
- Other measures
- IVIG
- Indicated in all cases of suspected toxic shock (either staphylococcal or streptococcal)
- Dose: 1 g/kg on day 1, then 0.5 g/kg on days 2 and 3
- More effective in neutralizing Streptococcus Pyogenes toxin, than Staphylococcus Aureus
- Overall, expensive intervention with underwhelming efficacy
- Plasmapheresis
- NOT effective in trials
-
Acute Kidney Injury
-
Acute Respiratory Distress Syndrome
- High mortality rate (esp. Streptococcal toxic shock)
- Chambers (2015) Toxic Shock Syndrome, Sanford Guide to Antimicrobial Therapy, accessed 4/13/2015
- Stevens (2014) Toxic Shock Syndrome, UpToDate, accessed 4/13/2015
- Venkataraman (2014) Toxic Shock Syndrome, Medscape EMedicine, accessed 4/13/2015
- Werner and Long (2023) Toxic Shock Syndrome, EM:Rap, accessed 8/1/2023
-
Lappin (2009) Lancet Infect Dis 9(5): 281-90 +PMID:19393958 [PubMed]
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