What is the treatment for toxic shock syndrome?

Treatment for Toxic Shock Syndrome

The treatment for toxic shock syndrome requires clindamycin and antitoxin therapies for cases with refractory hypotension, along with appropriate antibiotics for the causative organism and aggressive source control. 1, 2

Initial Management

• Administer empiric antimicrobials within 1 hour of identifying severe sepsis, with blood cultures obtained before antibiotics when possible (without delaying treatment) 1
• Begin fluid resuscitation with isotonic crystalloids or albumin with boluses up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension and improve perfusion 1
• For respiratory distress and hypoxemia, start with face mask oxygen or high-flow nasal cannula oxygen if needed 1
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 1

Antibiotic Therapy

• For streptococcal toxic shock syndrome:

  • Combination of clindamycin (600-900 mg IV every 8 hours) and penicillin 2
  • Clindamycin suppresses toxin production and modulates cytokine release 2, 3

• For staphylococcal toxic shock syndrome:

  • Vancomycin (30-60 mg/kg/day IV in 2-4 divided doses) in MRSA-prevalent areas 2, 3
  • Add clindamycin to suppress toxin production 2, 4
  • Alternative agents for penicillin allergies include linezolid, quinupristin/dalfopristin, or daptomycin 2

Source Control

• Early and aggressive source control is paramount in severe sepsis and septic shock (grade 1D) 1
• Conditions requiring debridement or drainage include necrotizing pneumonia, necrotizing fasciitis, gangrenous myonecrosis, empyema, and abscesses 1
• Perforated viscus requires repair and peritoneal washout 1
• Remove any potential sources such as tampons, wound packing, or foreign bodies 3, 5

Hemodynamic Support

• For patients unresponsive to fluid resuscitation, begin peripheral inotropic support until central venous access can be attained 1
• For shock with low cardiac index and low blood pressure, norepinephrine can be added to epinephrine to increase diastolic blood pressure and systemic vascular resistance 1
• For patients with low cardiac output and elevated systemic vascular resistance with normal blood pressure, consider vasodilator therapies in addition to inotropes 1

Adjunctive Therapies

• Consider intravenous immunoglobulin (IVIG) in refractory toxic shock syndrome, though efficacy is not definitively established 2, 4
• Timely hydrocortisone therapy in children with fluid refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency 1
• Continue antimicrobial therapy until repeated operative procedures are no longer needed, the patient has demonstrated obvious clinical improvement, and fever has been absent for 48-72 hours 2

Management of Refractory Shock

• Rule out and correct potentially reversible causes including:

  • Pericardial effusion (pericardiocentesis)
  • Pneumothorax (thoracentesis)
  • Hypoadrenalism (adrenal hormone replacement)
  • Hypothyroidism (thyroid hormone replacement)
  • Ongoing blood loss (blood replacement/hemostasis)
  • Increased intra-abdominal pressure (peritoneal catheter or abdominal release)
  • Necrotic tissue (nidus removal) 1

• Consider ECMO for refractory pediatric septic shock and respiratory failure when other measures fail 1

Common Pitfalls to Avoid

• Delaying antibiotic administration - empiric antimicrobials must be given within 1 hour of identification of severe sepsis 2
• Using β-lactam antibiotics alone for streptococcal TSS - clindamycin should always be included to suppress toxin production 2
• Inadequate source control - surgical debridement is often necessary for necrotizing infections 2, 6
• Insufficient fluid resuscitation - large volumes may be necessary due to capillary leak and third-spacing 7
• Failure to recognize TSS early - symptoms can progress rapidly within hours to hypovolemic hypotension 7, 5