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


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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