Toxic shock syndrome

Question 1

Define toxic shock syndrome.

Answer 1

An exotoxin-mediated illness caused by bacterial infection.

Question 2

Which bacteria commonly trigger TSS? What is the most common route of infection for each?

Answer 2

Streptococcus pyogenes -

• Produces superantigens (SPEA and SPEB) and virulence factors (e.g. M1 and M3)
• Commonly associated with infected cutaneous site

Staphylococcus aureus - MSSA/MRSA

• Produces TSS toxin-1 or enterotoxins (B, C, D, E, H)
• Associated with extended tampon use, postpartum infections, and other sites of infection with the organism.

Question 3

What 2 groups is staphylococcal TSS often split into?

Answer 3

Menstrual TSS - occurs in women during menstruation with extended use of a single tampon or, historically, with highly absorbable tampons.

Non-menstrual TSS - can result from a variety of staphylococcal post-partum vaginal and caesarean wound infection

Question 4

What are the risk factors for TSS?

Answer 4

• DM
• Alcoholism
• Minor trauma
• Surgery e.g. vaginal delivery, breast, C section, hysterectomy, liposuction
• Single tampont used continuously for consecutive days during menses
• Highly absorbent tampon use

Question 5

How common is TSS?

Answer 5

~20,000 cases in US each year, less than 1 in 1 million annual incidence in UK

85% sporadic, 10% hospital acquired

Question 6

What are the clinical features of TSS?

Answer 6

• Severe diffuse or localised pain in an extremity
• Fever
• Localised swelling or erythema
• Hypotension +/- sepsis
• Diffuse, scarlatina-like erythematous rash

Question 7

What is the management of TSS?

Answer 7

Supportive care in an ICU - removal of source e.g. tampon

Early empirical antibiotic treatment (e.g. clindamycin 900mg IV 8-hourly AND meropenem 1g IV 8-hourly) and further culture-sensitive antibiotic treatment.

Surgical debridement - may be needed for deep-seated streptococcal infections; sequential debridements of infected tissue are often needed,

Confirmed streptococcal TSS:

• Clindamycin + benpen/vancomycin
• IVIG

Confirmed staphylococcal TSS:

• Clindamycin + vanc/linezolid
• Topical mupirocin 2% - to eradicate NASAL culture

Question 8

How do you diagnose TSS?

Answer 8

MC&S of blood or any suspected site - postive for GAS or S. aureus.

Question 9

What are the complications of TSS and what is the prognosis?

Answer 9

• Bacteraemia
• ARDS
• DIC
• Renal failure
• Wound sequelae
• Waterhouse-Friderichsen syndrome - acute haemorrhagic adrenal insufficiency
• Neuropsychiatric sequelae

Prognosis: streptococcal TSS has mortality as high as 30-85% even with early treatment, staphylococcal TSS mortality ~5%. Shock is the most important predictor of death.