What is the treatment for Toxic Shock Syndrome (TSS)?

Treatment of Toxic Shock Syndrome (TSS)

The treatment of Toxic Shock Syndrome requires immediate aggressive fluid resuscitation, early antibiotic therapy with a combination of a bactericidal agent plus clindamycin, and prompt source control to reduce mortality and morbidity. 1

Initial Resuscitation and Supportive Care

• Fluid Resuscitation:

  • Administer crystalloids in boluses of up to 20 mL/kg over 5-10 minutes
  • Titrate to reverse hypotension, increase urine output, and normalize peripheral perfusion 1
  • Avoid overaggressive fluid administration which can cause pulmonary, cutaneous, and intestinal edema 1

• Vasopressor Support:

  • Initiate if fluid resuscitation fails to restore blood pressure 1
  • Begin peripheral inotropic support until central venous access can be established 1

• Respiratory Support:

  • Start with face mask oxygen or high-flow nasal cannula for respiratory distress 1
  • Consider mechanical ventilation if respiratory failure develops 1
  • ECMO may be considered for refractory septic shock and respiratory failure 1

Antimicrobial Therapy

• Timing: Initiate antibiotics within 1 hour of identifying severe sepsis/TSS 1

• For Staphylococcal TSS:

  • Clindamycin (600-900 mg IV every 8 hours) PLUS
  • Antistaphylococcal penicillin (nafcillin/oxacillin) OR vancomycin for MRSA-prevalent areas 1

• For Streptococcal TSS:

  • Clindamycin PLUS penicillin 1
  • Clindamycin is critical as it suppresses toxin production even when bacteria are not actively replicating 1, 2

• Duration: Continue antibiotics until clinical improvement and resolution of organ dysfunction (typically 10-14 days)

Source Control

• Critical step: Early and aggressive source control is essential 1

• Surgical intervention:

  • Aggressive surgical debridement for necrotizing infections 1
  • Adequate drainage of abscesses or collections 1
  • Removal of foreign bodies (e.g., tampons in menstrual TSS) 3

• Wound Management:

  • Handle skin with extreme care to minimize further damage 1
  • Gently cleanse wounds using warmed sterile water, saline, or diluted chlorhexidine 1
  • Apply non-adherent dressings to denuded areas 1
  • Consider silver-containing products for infected areas 1
  • Avoid aggressive debridement of detached skin which may worsen the condition 1

Adjunctive Therapies

• Intravenous Immunoglobulin (IVIG):

  • Consider IVIG in patients with streptococcal TSS 4
  • Evidence for IVIG is mixed but may be beneficial in refractory cases 4, 2
  • Typical dose: 25 g/day for three consecutive days 4

• Corticosteroids:

  • Consider hydrocortisone in cases of refractory shock with suspected adrenal insufficiency 1

Monitoring and Evaluation

• Regular assessment of:

  • Vital signs and hemodynamic parameters
  • Organ function (renal, hepatic, respiratory)
  • Electrolyte balance
  • Signs of secondary infection in denuded skin areas 1

• Laboratory monitoring:

  • Complete blood count (anemia, thrombocytopenia)
  • Liver enzymes
  • Coagulation studies
  • Renal function 3

Common Pitfalls to Avoid

• Delayed recognition of TSS leading to delayed treatment 5
• Inadequate fluid resuscitation in the early phase 1
• Delayed source control which can worsen outcomes 1
• Omitting clindamycin from the antibiotic regimen 1, 6
• Using adhesive dressings on fragile skin 1
• Waiting for culture results before starting antibiotics 1

The Seven Rs Approach to TSS Management

1. Recognition: Early identification of signs and symptoms
2. Resuscitation: Aggressive fluid and hemodynamic support
3. Removal of source of infection
4. Rational choice of antibiotics (bactericidal plus toxin-suppressing)
5. Role of adjunctive treatment (clindamycin and IVIG)
6. Review of progress regularly
7. Reduce risk of secondary cases in close contacts 5

TSS is a medical emergency with high mortality if not promptly recognized and treated. The combination of early aggressive resuscitation, appropriate antibiotics including clindamycin, and source control forms the cornerstone of effective management.