Toxic shock syndrome: Difference between revisions

Latest revision as of 10:34, 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 ≤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

@@ Line 1: / Line 1: @@
+== Background ==
-* Severe septic shock caused by certain bacterial infections
+* 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 [[Clostridial toxic shock syndrome|''Clostridium sordelli'']]
 == Criteria ==
 {| class="wikitable"
 ! Criteria
-! Staphylococcal
+! [[Staphylococcal toxic shock syndrome|Staphylococcal]]
-! Streptococcal
+! [[Streptococcal toxic shock syndrome|Streptococcal]]
 |-
 | Confirmed
@@ Line 57: / Line 59: @@
 |}
+== Management ==
-== Staphylococcal Toxic Shock Syndrome ==
+{| class="wikitable"
+!
-Source: [https://wwwn.cdc.gov/nndss/conditions/toxic-shock-syndrome-other-than-streptococcal/case-definition/2011/ CDC case definition 2011]
+!First-Line
+!Beta-lactam Allergy
-=== Clinical Criteria ===
+!Notes
+|-
-An illness with the following clinical manifestations:
+|[[Streptococcus pyogenes]]
+|[[Penicillin G]] and [[clindamycin]]
-* '''Fever:''' temperature greater than or equal to 102.0°F (greater than or equal to 38.9°C)
+|[[Macrolide]] or [[fluoroquinolone]], and [[clindamycin]]
-* '''Rash:''' diffuse macular erythroderma
+|Macrolide and fluoroquinolone resistance increasing
-* '''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
+|MLS-resistant [[Streptococcus pyogenes]]
-* '''Multisystem involvement''' (three or more of the following organ systems):
+|[[Penicillin G]], and [[vancomycin]] or [[teicoplanin]]
-** '''Gastrointestinal:''' vomiting or diarrhea at onset of illness
+|[[Vancomycin]] or [[teicoplanin]]
-** '''Muscular:''' severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
+|Macrolide resistance associated with clindamycin resistance
-** '''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
+|Methicillin-susceptible [[Staphylococcus aureus]]
-** '''Hepatic:''' total bilirubin, alanine aminotransferase enzyme, or asparate aminotransferase enzyme levels at least twice the upper limit of normal for laboratory
+|[[Cloxacillin]] or [[nafcillin]] or [[cefazolin]], and [[clindamycin]]
-** '''Hematologic:''' platelets less than 100,000/mm3
+|[[Clarithromycin]] and [[clindamycin]]
-** '''Central nervous system:''' disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent
+|
+|-
-=== Laboratory Criteria for Diagnosis ===
+|Methicillin-resistant [[Staphylococcus aureus]]
+|[[Clindamycin]] or [[linezolid]], and [[vancomycin]] or [[teicoplanin]]
-Negative results on the following tests, if obtained:
+|
+|
+|-
+|Glycopeptide resistant or intermediate [[Staphylococcus aureus]]
+|[[Linezolid]] and [[clindamycin]] (if susceptible)
+|
+|Incidence increasing. Geographical patterns highly variable
+|}
+== Further Reading ==
-* Blood or cerebrospinal fluid cultures (blood culture may be positive for Staphylococcus aureus)
-* Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles
+* 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]
-=== Case Classification ===
+[[Category:Infectious syndromes]]
-* 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