From the Guidelines
Management of a 1-year-old with suspected toxic shock syndrome (TSS) requires immediate hospitalization in a pediatric intensive care unit and initiation of empiric antibiotic therapy with vancomycin and clindamycin, as well as aggressive fluid resuscitation and supportive care for organ dysfunction. The most recent and highest quality study 1 emphasizes the importance of supportive care in the management of Stevens-Johnson syndrome/toxic epidermal necrolysis, which can be applied to the management of TSS. Start with aggressive fluid resuscitation using isotonic crystalloids (20 ml/kg boluses) to address hypotension and maintain adequate perfusion. Initiate empiric antibiotic therapy immediately with vancomycin (15 mg/kg IV every 6 hours) plus clindamycin (10 mg/kg IV every 8 hours) to target Staphylococcus aureus and Streptococcus pyogenes, the most common causative organisms. Clindamycin is particularly important as it inhibits toxin production, as suggested by the Surviving Sepsis Campaign guidelines 1. Identify and remove any potential source of infection, such as foreign bodies or abscesses. Obtain appropriate cultures (blood, wound, throat) before starting antibiotics if possible, but don't delay treatment. Monitor vital signs continuously, maintain adequate oxygenation, and be prepared for vasopressor support if fluid resuscitation doesn't correct hypotension. Intravenous immunoglobulin (IVIG) at 1-2 g/kg may be considered in severe cases to neutralize circulating toxins, as mentioned in the guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people 1. Provide supportive care for organ dysfunction, including respiratory support if needed.
Some key points to consider in the management of TSS include:
- Aggressive fluid resuscitation to maintain adequate perfusion
- Empiric antibiotic therapy with vancomycin and clindamycin to target common causative organisms
- Identification and removal of potential sources of infection
- Continuous monitoring of vital signs and preparation for vasopressor support if needed
- Consideration of IVIG in severe cases to neutralize circulating toxins
- Supportive care for organ dysfunction, including respiratory support if needed
It is essential to prioritize the management of TSS based on the most recent and highest quality evidence, which emphasizes the importance of supportive care and empiric antibiotic therapy in reducing morbidity and mortality. The guidelines from the Surviving Sepsis Campaign 1 and the British Association of Dermatologists' guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in children and young people 1 provide valuable recommendations for the management of TSS.
From the Research
Management Approach for Toxic Shock Syndrome (TSS) in a 1-year-old Patient
The management approach for a 1-year-old patient with suspected Toxic Shock Syndrome (TSS) includes:
- Hemodynamic stabilization and appropriate antimicrobial therapy to eradicate the bacteria 2
- Supportive therapy, aggressive fluid resuscitation, and vasopressors remain the main elements 2
- An adjuvant therapeutic strategy may include agents that can block superantigens, such as intravenous immunoglobulin that contains superantigen neutralizing antibodies 2, 3
- Early recognition of this disease is important, because the clinical course is fulminant and the outcome depends on the prompt institution of therapy 2
Key Considerations
- TSS is an acute, toxin-mediated illness, characterized by fever, rash, hypotension, multiorgan involvement, and desquamation 2, 4, 5
- The disease can be caused by Staphylococcus aureus and Streptococcus pyogenes, with different epidemiology and clinical syndromes 2
- Mortality associated with TSS can be high, especially if not recognized and treated promptly 2, 4