Toxic shock syndrome

• Severe septic shock caused by certain bacterial infections

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

Staphylococcal Toxic Shock Syndrome

Source: CDC case definition 2011

Clinical Criteria

An illness with the following clinical manifestations:

• Fever: temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C)
• Rash: diffuse macular erythroderma
• Desquamation: 1-2 weeks after onset of rash
• 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
• Multisystem involvement (three or more of the following organ systems):
  • Gastrointestinal: vomiting or diarrhea at onset of illness
  • Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
  • Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
  • 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
  • Hepatic: total bilirubin, alanine aminotransferase enzyme, or asparate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory
  • Hematologic: platelets less than 100,000/mm3
  • Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent

Laboratory Criteria for Diagnosis

Negative results on the following tests, if obtained:

• Blood or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus)
• Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles

Case Classification

• Probable: A case which meets the laboratory criteria and in which four of the five clinical criteria described above are present
• 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

Streptococcal Toxic Shock Syndrome

Case definition

Source: CDC case definition 2010

Clinical Description

Streptococcal toxic shock syndrome (STSS) is a severe illness associated with invasive or noninvasive group A streptococcal (Streptococcus pyogenes) infection. STSS may occur with infection at any site but most often occurs in association with infection of a cutaneous lesion. Signs of toxicity and a rapidly progressive clinical course are characteristic, and the case fatality rate may exceed 50%.

Clinical Criteria

An illness with the following clinical manifestations*:

• Hypotension defined by a systolic blood pressure less than or equal to 90 mm Hg for adults or less than the fifth percentile by age for children aged less than 16 years.
• Multi-organ involvement characterized by two or more of the following:
  • Renal impairment: Creatinine greater than or equal to 2 mg/dL (greater than or equal to 177 µmol/L) for adults or greater than or equal to twice the upper limit of normal for age. In patients with preexisting renal disease, a greater than twofold elevation over the baseline level.
  • Coagulopathy: Platelets less than or equal to 100,000/mm3 (less than or equal to 100 x 106/L) or disseminated intravascular coagulation, defined by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products.
  • Liver involvement: Alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than or equal to twice the upper limit of normal for the patient's age. In patients with preexisting liver disease, a greater than twofold increase over the baseline level.
  • Acute respiratory distress syndrome: defined by acute onset of diffuse pulmonary infiltrates and hypoxemia in the absence of cardiac failure or by evidence of diffuse capillary leak manifested by acute onset of generalized edema, or pleural or peritoneal effusions with hypoalbuminemia.
  • A generalized erythematous macular rash that may desquamate.
  • Soft-tissue necrosis, including necrotizing fasciitis or myositis, or gangrene.

• Clinical manifestations do not need to be detected within the first 48 hours of hospitalization or illness, as specified in the 1996 case definition. The specification of the 48 hour time constraint was for purposes of assessing whether the case was considered nosocomial, not whether it was a case or not.

Laboratory Criteria for Diagnosis

• Isolation of group A Streptococcus.

Case Classification

• Probable: A case that meets the clinical case definition in the absence of another identified etiology for the illness and with isolation of group A Streptococcus from a non-sterile site.
• Confirmed: A case that meets the clinical case definition and with isolation of group A Streptococcus from a normally sterile site (e.g., blood or cerebrospinal fluid or, less commonly, joint, pleural, or pericardial fluid).

Management

• Penicillin or other antistreptococcal beta-lactam
• Plus clindamycin
  • All GAS is susceptible to penicillin, so we need that
  • Erythromycin resistance is still rare, but increasing
  • Clindamycin/erythromycin may be more active in animal models of necrotizing fasciitis and myonecrosis
  • PBPs are not expressed during stationary-phase growth, so penicillin is less helpful when there is a large burden of bacteria (Eagle phenomenon)
  • Clindamycin blocks protein production (exotoxin and M protein)
  • Clindamycin has a longer half-life than penicillin
  • The two antibiotics are not antagonistic in vitro, so combination shouldn't cause problems
  • Clindamycin and azithromycin suppress cytokine production
• And maybe with IVIg