Staphylococcal Toxic Shock Syndrome

OVERVIEW

• staphylococcal toxin producing infection -> intoxication of exotoxins (TSS-1, 2 or 3 enterotoxin)-> toxic shock syndrome
• TSST acts as a superantigen activating T-cells directly and causing massive cytokine release

HISTORY

• rapid onset
• entry port for staphylococcus (tampon, swab, infected skin lesion, respiratory tract, post partum, osteomyelitis)
• systemic symptoms (fever, chills, rigors)
• myalgia
• GI upset – vomiting and diarrhoea
• headache
• sore throat
• shock with multi-organ failure

EXAMINATION

• fever
• tachycardia
• hypotension
• confusion
• generalised macular erythematous of skin with desquamation over time
• non-purulent conjunctivitis
• infected entry port

INVESTIGATIONS

• blood cultures (are usually negative)
• routine bloods

MANAGEMENT

• early recognition
• early and adequate antibiotic therapy
• source control

Resuscitation

A – may be obtunded and require airway protection
B – ventilation to relieve work of breathing, may develop ALI/ARDS
C – large bore IV access, aggressive fluid resuscitation – often require alot, inotropic and vasopressor support as tolerated, invasive monitoring

Specific Therapy

• remove source – remove tampon, debridement
• antibiotics – flucloxacillin 50mg/kg Q 6hrly or cephazolin 50mg/kg Q8 hrly
• clindamycin 25-40mg/kg/day in divided doses – controversial but believed to attenuate the toxin production
• immunoglobulin IV 2g/kg LD -> 0.4g/kg for 5 days – mechanism uncertain ?binding of toxin
• hyperbaric oxygen – controversial and not always readily available
• low dose steroids – in refractory shock

General Therapy

• Elevated creatinine and urea – fluid resuscitation
• Hypoglycaemia – replacement
• Low protein and albumin – supportive care
• Elevated bilirubin and transaminases – supportive care
• Metabolic acidosis – resuscitation
• Nutrition
• Thromboprophylaxis

References and Links

• Clinical Case – Sick, Shocked and Sunburned?