What is the management of toxic shock syndrome?

Management of Toxic Shock Syndrome

The management of toxic shock syndrome requires immediate hospitalization, aggressive fluid resuscitation, specific antibiotics (including clindamycin plus antistaphylococcal or antistreptococcal agents), and control of the infectious source. 1

Initial Resuscitation and Supportive Care

• Fluid Resuscitation: Administer crystalloids or albumin in boluses of up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension, increase urine output, and normalize peripheral perfusion 2, 1

  • Avoid overaggressive fluid resuscitation as it may cause pulmonary, cutaneous, and intestinal edema 1
  • Monitor for signs of fluid overload (hepatomegaly, rales)

• Vasopressors: Initiate if fluid resuscitation fails to restore blood pressure 1

  • Begin peripheral inotropic support until central venous access can be attained 2

• Respiratory Support: Start with face mask oxygen or high-flow nasal cannula for respiratory distress and hypoxemia 2

  • Consider mechanical ventilation if needed, after appropriate cardiovascular resuscitation 2

Antimicrobial Therapy

• Initiate antibiotics within 1 hour of identifying severe sepsis/TSS 2, 1

  • For Staphylococcal TSS: Clindamycin (600-900 mg IV every 8 hours) plus:

    • Antistaphylococcal penicillin (nafcillin/oxacillin) OR
    • Vancomycin for MRSA-prevalent areas 1, 3

  • For Streptococcal TSS: Clindamycin plus penicillin 1, 3

• Rationale for Clindamycin: Suppresses toxin production even when bacteria are not actively replicating 1, 3

• Duration: Continue antibiotics for at least 10-14 days, depending on clinical response and source control 3, 4

Source Control

• Aggressive surgical debridement is essential for necrotizing infections 1, 5

  • Early and aggressive source control is critical 2

• Wound Management:

  • Gently cleanse wounds using warmed sterile water, saline, or diluted chlorhexidine 2, 1
  • Apply non-adherent dressings to denuded dermis 1
  • Consider silver-containing products for areas with signs of infection 2, 1
  • Handle skin with extreme care to minimize further damage 1

• For menstrual TSS: Remove tampons or other vaginal devices 6

• Drain abscesses or collections to control the infectious source 1

Adjunctive Therapies

• Intravenous Immunoglobulin (IVIG): Consider in refractory cases 1, 7

  • May be particularly beneficial in streptococcal TSS 7
  • Dosing typically 1-2 g/kg over 2-3 days 5

• Corticosteroids: Consider hydrocortisone in cases of refractory shock with suspected adrenal insufficiency 2, 1

  • Timely hydrocortisone therapy in fluid-refractory, catecholamine-resistant shock 2

• Extracorporeal Membrane Oxygenation (ECMO): Consider for refractory septic shock and respiratory failure 2, 1

Monitoring and Complication Management

• Monitor for signs of systemic infection:

  • Confusion, hypotension, reduced urine output, reduced oxygen saturation 2, 1
  • Monitor electrolytes, renal and hepatic function 1

• Evaluate for and reverse:

  • Pneumothorax, pericardial tamponade, endocrine emergencies in refractory shock 2, 1
  • Secondary infections of denuded skin areas 2, 1

• Maintain ambient temperature between 25°C and 28°C to prevent hypothermia 1

Common Pitfalls to Avoid

1. Delaying antimicrobial therapy while waiting for culture results 1
2. Indiscriminate prophylactic antibiotics which may increase skin colonization, particularly with Candida albicans 2
3. Overaggressive fluid resuscitation causing pulmonary, cutaneous, and intestinal edema 2, 1
4. Failure to recognize and control the source of infection 1, 5
5. Using adhesive dressings that can further damage fragile skin 1
6. Neglecting clindamycin as part of the antibiotic regimen, which is crucial for toxin suppression 1, 3

Special Considerations

• Transfer to specialized care: Consider transfer to an intensive care unit or burn center if more than 10% of body surface area is affected 1
• Recurrence prevention: Educate patients about avoiding conditions that favor toxin production (e.g., tampon use during menstruation for those with previous menstrual TSS) 6

Early recognition and aggressive management of toxic shock syndrome are essential for improving outcomes and reducing mortality. The comprehensive approach focusing on resuscitation, appropriate antibiotics, source control, and supportive care can significantly improve survival rates.