Toxic shock syndrome

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 ≤90 mmHg	SBP ≤90 mmHg
Fever	temp ≥38.9ºC
Skin	diffuse macular erythroderma followed by desquamation	generalized erythematous macular rash that may desquamate
GI	n/v/d at onset
Resp		ARDS
MSK	myalgia ± CK ≥2x ULN	soft-tissue necrosis (e.g. nec.fasc)
Mucosa	hyperemia of any mucosa
Nephro	Creatinine ≥2x ULN, or pyuria without UTI	Creatinine ≥177 or ≥2x ULN or ≥2x baseline
Hepatic	bili/ALT/AST ≥2x ULN	ALT/AST/bili ≥2x ULN or ≥2x baseline
Heme	thrombocytopenia <100	thrombocytopenia ≤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