What is the treatment for toxic shock syndrome?

Treatment for Toxic Shock Syndrome

The treatment for toxic shock syndrome requires immediate administration of empiric antimicrobials within 1 hour of identification, aggressive fluid resuscitation with isotonic crystalloids or albumin, and early source control through appropriate debridement or drainage of infected sites. 1

Initial Management

• Begin fluid resuscitation with isotonic crystalloids or albumin, using boluses up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension and improve perfusion 1
• Administer empiric antimicrobials within 1 hour of identifying severe sepsis, with blood cultures obtained before antibiotics when possible 1
• Provide respiratory support with face mask oxygen or high-flow nasal cannula oxygen for patients with respiratory distress and hypoxemia 1
• Monitor for signs of shock including altered mental status, prolonged capillary refill (>2 seconds), decreased urine output (<1 mL/kg/hr), and hemodynamic instability 1

Antibiotic Therapy

• For streptococcal toxic shock syndrome, use a combination of clindamycin (600-900 mg IV every 8 hours) and penicillin, as clindamycin suppresses toxin production and modulates cytokine release 1
• For staphylococcal toxic shock syndrome, administer a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid 2
• Continue antibiotic therapy for at least 10-14 days depending on clinical response and source control 2

Source Control

• Early and aggressive source control is paramount in severe sepsis and septic shock 1
• Remove any potential sources of infection (e.g., tampons, nasal packing, wound packing) 2
• Perform surgical debridement or drainage for conditions such as necrotizing fasciitis, abscesses, or infected wounds 1
• Repair perforated viscus and perform peritoneal washout if indicated 1

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, add norepinephrine to epinephrine to increase diastolic blood pressure and systemic vascular resistance 3, 1
• Once adequate blood pressure is achieved, consider adding dobutamine, type III phosphodiesterase inhibitors (particularly enoximone), or levosimendan to improve cardiac index and central venous oxygen saturation 3

Adjunctive Therapies

• Consider intravenous immunoglobulin (IVIG) in refractory toxic shock syndrome, though efficacy is not definitively established 1, 4
• Administer hydrocortisone therapy in patients with fluid refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency 1
• Provide thyroid replacement with triiodothyronine for thyroid insufficiency 3

Management of Refractory Shock

• Rule out and correct potentially reversible causes of refractory shock, including: 3, 1
  • Pericardial effusion (treat with pericardiocentesis)
  • Pneumothorax (perform thoracentesis)
  • Hypoadrenalism (administer adrenal hormone replacement)
  • Hypothyroidism (provide thyroid hormone replacement)
  • Ongoing blood loss (ensure blood replacement/hemostasis)
  • Increased intra-abdominal pressure (place peritoneal catheter or perform abdominal release)
  • Necrotic tissue (remove nidus)
  • Inappropriate source control of infection (remove nidus and use antibiotics with the lowest minimum inhibitory concentration)
• Consider ECMO for refractory shock when other measures fail, though expected survival with ECMO is no greater than 50% 3, 1

Prevention of Recurrence

• Educate patients about avoiding conditions that might favor toxin production (e.g., use of tampons during menstruation for menstrual-related TSS) 5
• Complete the full course of antibiotics to prevent recurrence 5
• Consider decolonization strategies for patients with recurrent staphylococcal infections 2

Pitfalls and Caveats

• Do not rely solely on diagnostic criteria for definitive diagnosis; maintain a high index of suspicion in specific situations (e.g., young females with unexplained shock during menstruation, patients with recent surgery or soft tissue infections) 2, 6
• Distinguish toxic shock syndrome from other conditions that may present similarly, such as septic shock from other causes, dengue hemorrhagic fever, or other exanthematous illnesses 7
• In newborns, distinguish septic shock from cardiogenic shock caused by closure of the patent ductus arteriosus in newborns with ductal-dependent complex congenital heart disease 3
• Recognize that symptoms may progress rapidly (within hours) from fever, pharyngitis, diarrhea, vomiting, myalgia, and rash to hypovolemic hypotension 5