From the Guidelines
Management of toxic shock syndrome requires prompt recognition and aggressive treatment, with the most recent and highest quality study recommending clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension 1. The initial management includes immediate removal of any potential source, fluid resuscitation with crystalloids to correct hypotension, and empiric antibiotic therapy.
- The recommended antibiotic regimen consists of vancomycin 15-20 mg/kg IV every 8-12 hours plus clindamycin 600-900 mg IV every 8 hours, as clindamycin suppresses toxin production even when bacteria aren't actively dividing 1.
- Surgical debridement is essential for wound-associated TSS to remove infected tissue, with the decision to undertake aggressive surgery based on several considerations, including no response to antibiotics, profound toxicity, and skin necrosis with easy dissection along the fascia 1.
- Vasopressors, such as norepinephrine, may be needed for persistent hypotension despite fluid resuscitation.
- Intravenous immunoglobulin (IVIG) at 1-2 g/kg over 1-2 days can be considered in severe cases to neutralize circulating toxins, although its efficacy is still being studied, with some studies showing potential benefits 1 and others showing no clear difference in mortality or serious adverse events 1.
- Supportive care in an ICU setting is typically required, with close monitoring of organ function and management of complications such as ARDS, DIC, or renal failure.
- Early infectious disease consultation is recommended to guide therapy, and patient education about avoiding tampon use during the recovery period is essential for menstrual TSS cases. Key points to consider in the management of toxic shock syndrome include:
- Prompt recognition and aggressive treatment
- Immediate removal of any potential source
- Fluid resuscitation with crystalloids
- Empiric antibiotic therapy with vancomycin and clindamycin
- Surgical debridement for wound-associated TSS
- Vasopressors for persistent hypotension
- Consideration of IVIG in severe cases
- Supportive care in an ICU setting
- Early infectious disease consultation
- Patient education to prevent future episodes.
From the Research
Management of Toxic Shock Syndrome
The management of toxic shock syndrome (TSS) involves a combination of treatments, including:
- Intravenous fluids to manage hypotension and prevent organ failure 2
- Source control, such as surgical debridement or drainage of infected wounds 2, 3
- Antibiotics, including a penicillinase-resistant penicillin, cephalosporin, or vancomycin, along with either clindamycin or linezolid 2, 3
- Adjunctive treatments, such as intravenous immunoglobulins (IVIG), which may help reduce morbidity and mortality 4, 5, 6
Antibiotic Treatment
The choice of antibiotics depends on the suspected or confirmed causative agent, with options including:
- Penicillinase-resistant penicillin, such as nafcillin or oxacillin 2
- Cephalosporin, such as cefazolin or ceftriaxone 2
- Vancomycin, particularly in areas with high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) 2
- Clindamycin or linezolid, which may be added to the regimen to enhance toxin suppression and improve outcomes 2, 3
Adjunctive Treatments
Intravenous immunoglobulins (IVIG) have been shown to be effective as an adjunctive treatment for TSS, particularly in cases caused by Group A Streptococcus (GAS) 4, 5, 6. IVIG may help reduce the production of pro-inflammatory cytokines and superantigens, thereby mitigating the severity of the disease.