Treatment of Toxic Shock Syndrome
The treatment of toxic shock syndrome requires immediate administration of empiric antimicrobials within 1 hour of identification, aggressive fluid resuscitation, and the addition of clindamycin to inhibit toxin production, with early and aggressive source control. 1
Initial Resuscitation and Stabilization
Hemodynamic Support (First 5-15 minutes)
- Push boluses of 20 mL/kg isotonic saline or colloid up to and over 60 mL/kg until perfusion improves 1
- If rales or hepatomegaly develop, switch to inotropic support
- Correct hypoglycemia and hypocalcemia
- For fluid-refractory shock (after 15 minutes):
- Begin inotrope IV/IO therapy
- Obtain central access and airway if needed
- For cold shock: Titrate central dopamine or epinephrine
- For warm shock: Titrate central norepinephrine 1
Catecholamine-Resistant Shock (After 60 minutes)
- Consider hydrocortisone if at risk for adrenal insufficiency
- For cold shock with normal BP: Titrate fluid and epinephrine, aim for ScvO₂ > 70%
- For cold shock with low BP: Titrate fluid and epinephrine, consider norepinephrine
- For warm shock with low BP: Titrate fluid and norepinephrine 1
Antimicrobial Therapy
Empiric Antibiotics
- Administer within 1 hour of identification of TSS 1
- Obtain blood cultures before antibiotics when possible, but do not delay treatment
- Base empiric choice on local epidemiology (e.g., MRSA prevalence)
Specific Antibiotic Recommendations for TSS
- First-line combination therapy:
Rationale for Clindamycin
- Children are more prone to toxic shock due to lack of circulating antibodies to toxins
- Clindamycin reduces toxin production, which is essential in managing TSS 1
- Particularly important in patients with erythroderma and suspected toxic shock 1
Source Control
Early and Aggressive Infection Source Control
- Paramount in severe sepsis and septic shock 1
- Conditions requiring debridement or drainage:
- Necrotizing pneumonia
- Necrotizing fasciitis
- Gangrenous myonecrosis
- Empyema
- Abscesses 1
- Remove infected devices (e.g., tampons in menstrual TSS)
- Delay in appropriate antibiotics, inadequate source control, and failure to remove infected devices synergistically increase mortality 1
Adjunctive Therapies
Intravenous Immunoglobulin (IVIG)
- May be considered in refractory toxic shock syndrome 1
- Contains superantigen neutralizing antibodies 3
- Role is unclear but may benefit patients not responding to conventional therapy 1, 4
Management of Refractory Shock
- Rule out and correct:
- Pericardial effusion (pericardiocentesis)
- Pneumothorax (thoracentesis)
- Hypoadrenalism (adrenal hormone replacement)
- Ongoing blood loss (blood replacement/hemostasis)
- Increased intra-abdominal pressure 1
- For truly refractory cases, consider ECMO 1
Clinical Pearls and Pitfalls
Important Considerations
- TSS can be staphylococcal or streptococcal in origin, with different clinical presentations 4
- Streptococcal TSS often involves deeper infections like necrotizing fasciitis 3
- Mortality is higher in streptococcal TSS (5-10% in children) compared to staphylococcal TSS (3-5% in children) 3
Common Pitfalls
- Delaying antibiotics while waiting for cultures - antibiotics should be given within 1 hour 1
- Failing to add clindamycin - essential for toxin suppression 1, 2
- Inadequate source control - critical for successful treatment 1
- Missing underlying focus of infection - thorough examination is essential 5
- Underestimating fluid requirements - aggressive resuscitation is needed 1
High-Risk Populations
- Menstruating females using tampons (especially ultra-absorbent types) 5, 6
- Children with varicella infection 3
- Children using NSAIDs during infections 3
- Patients with surgical wounds, burns, or soft tissue injuries 2
Early recognition and aggressive management of toxic shock syndrome are essential to reduce morbidity and mortality in this potentially life-threatening condition.