Toxic shock syndrome: Difference between revisions
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== Background == |
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* Severe septic shock caused by certain bacterial infections |
* Severe septic shock caused by certain bacterial infections, primarily ''[[Staphylococcus aureus]]'' and ''[[Streptococcus pyogenes]]'' |
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** Caused by superantigens, which non-specifically activate a massive number of T-cells |
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*Similar syndrome can be caused by toxin production of [[Clostridial toxic shock syndrome|''Clostridium sordelli'']] |
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== Criteria == |
== Criteria == |
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{| class="wikitable" |
{| class="wikitable" |
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! Criteria |
! Criteria |
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! Staphylococcal |
! [[Staphylococcal toxic shock syndrome|Staphylococcal]] |
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! Streptococcal |
! [[Streptococcal toxic shock syndrome|Streptococcal]] |
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|- |
|- |
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| Confirmed |
| Confirmed |
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== Management == |
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== Staphylococcal Toxic Shock Syndrome == |
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{| class="wikitable" |
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! |
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Source: [https://wwwn.cdc.gov/nndss/conditions/toxic-shock-syndrome-other-than-streptococcal/case-definition/2011/ CDC case definition 2011] |
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!First-Line |
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!Beta-lactam Allergy |
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=== Clinical Criteria === |
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!Notes |
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|- |
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An illness with the following clinical manifestations: |
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|[[Streptococcus pyogenes]] |
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|[[Penicillin G]] and [[clindamycin]] |
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* '''Fever:''' temperature greater than or equal to 102.0Β°F (greater than or equal to 38.9Β°C) |
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|[[Macrolide]] or [[fluoroquinolone]], and [[clindamycin]] |
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* '''Rash:''' diffuse macular erythroderma |
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|Macrolide and fluoroquinolone resistance increasing |
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* '''Desquamation:''' 1-2 weeks after onset of rash |
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|- |
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* '''Hypotension:''' systolic blood pressure less than or equal to 90 mm Hg for adults or less than fifth percentile by age for children aged less than 16 years |
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|MLS-resistant [[Streptococcus pyogenes]] |
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* '''Multisystem involvement''' (three or more of the following organ systems): |
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|[[Penicillin G]], and [[vancomycin]] or [[teicoplanin]] |
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** '''Gastrointestinal:''' vomiting or diarrhea at onset of illness |
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|[[Vancomycin]] or [[teicoplanin]] |
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** '''Muscular:''' severe myalgia or creatine phosphokinase level at least twice the upper limit of normal |
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|Macrolide resistance associated with clindamycin resistance |
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** '''Mucous membrane:''' vaginal, oropharyngeal, or conjunctival hyperemia |
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|- |
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** '''Renal:''' blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria (greater than or equal to 5 leukocytes per high-power field) in the absence of urinary tract infection |
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|Methicillin-susceptible [[Staphylococcus aureus]] |
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** '''Hepatic:''' total bilirubin, alanine aminotransferase enzyme, or asparate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory |
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|[[Cloxacillin]] or [[nafcillin]] or [[cefazolin]], and [[clindamycin]] |
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** '''Hematologic:''' platelets less than 100,000/mm3 |
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|[[Clarithromycin]] and [[clindamycin]] |
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** '''Central nervous system:''' disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent |
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=== Laboratory Criteria for Diagnosis === |
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|Methicillin-resistant [[Staphylococcus aureus]] |
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|[[Clindamycin]] or [[linezolid]], and [[vancomycin]] or [[teicoplanin]] |
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Negative results on the following tests, if obtained: |
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|Glycopeptide resistant or intermediate [[Staphylococcus aureus]] |
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|[[Linezolid]] and [[clindamycin]] (if susceptible) |
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|Incidence increasing. Geographical patterns highly variable |
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== Further Reading == |
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* Blood or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus) |
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* Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles |
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* Gram-positive toxic shock syndromes. ''Lancet Infect Dis''. 2009;9(5):281-290. doi: [https://doi.org/10.1016/S1473-3099(09)70066-0 10.1016/S1473-3099(09)70066-0] |
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=== Case Classification === |
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[[Category:Infectious syndromes]] |
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* Probable: A case which meets the laboratory criteria and in which four of the five clinical criteria described above are present |
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* Confirmed: A case which meets the laboratory criteria and in which all five of the clinical criteria described above are present, including desquamation, unless the patient dies before desquamation occurs |
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Latest revision as of 14:34, 22 November 2022
Background
- Severe septic shock caused by certain bacterial infections, primarily Staphylococcus aureus and Streptococcus pyogenes
- Caused by superantigens, which non-specifically activate a massive number of T-cells
- Similar syndrome can be caused by toxin production of Clostridium sordelli
Criteria
| Criteria | Staphylococcal | Streptococcal |
|---|---|---|
| Confirmed | hypotension + fever + rash + desquamating + 3 or more other | hypotension + 2 or more other |
| Hypotension | SBP β€90 mmHg | SBP β€90 mmHg |
| Fever | temp β₯38.9ΒΊC | |
| Skin | diffuse macular erythroderma followed by desquamation | generalized erythematous macular rash that may desquamate |
| GI | n/v/d at onset | |
| Resp | ARDS | |
| MSK | myalgia Β± CK β₯2x ULN | soft-tissue necrosis (e.g. nec.fasc) |
| Mucosa | hyperemia of any mucosa | |
| Nephro | Creatinine β₯2x ULN, or pyuria without UTI |
Creatinine β₯177 or β₯2x ULN or β₯2x baseline |
| Hepatic | bili/ALT/AST β₯2x ULN | ALT/AST/bili β₯2x ULN or β₯2x baseline |
| Heme | thrombocytopenia <100 | thrombocytopenia β€100, or DIC (INR/fibrinogen/D-dimer) |
| CNS | altered LOC without focal signs |
Management
| First-Line | Beta-lactam Allergy | Notes | |
|---|---|---|---|
| Streptococcus pyogenes | Penicillin G and clindamycin | Macrolide or fluoroquinolone, and clindamycin | Macrolide and fluoroquinolone resistance increasing |
| MLS-resistant Streptococcus pyogenes | Penicillin G, and vancomycin or teicoplanin | Vancomycin or teicoplanin | Macrolide resistance associated with clindamycin resistance |
| Methicillin-susceptible Staphylococcus aureus | Cloxacillin or nafcillin or cefazolin, and clindamycin | Clarithromycin and clindamycin | |
| Methicillin-resistant Staphylococcus aureus | Clindamycin or linezolid, and vancomycin or teicoplanin | ||
| Glycopeptide resistant or intermediate Staphylococcus aureus | Linezolid and clindamycin (if susceptible) | Incidence increasing. Geographical patterns highly variable |
Further Reading
- Gram-positive toxic shock syndromes. Lancet Infect Dis. 2009;9(5):281-290. doi: 10.1016/S1473-3099(09)70066-0
