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

Treatment for Toxic Shock Syndrome

Toxic shock syndrome requires immediate aggressive resuscitation with isotonic crystalloids, empiric broad-spectrum antibiotics within 1 hour including clindamycin plus either penicillin (for streptococcal TSS) or vancomycin (for staphylococcal TSS in MRSA-prevalent areas), and urgent surgical source control when indicated. 1, 2

Immediate Resuscitation and Hemodynamic Support

Fluid resuscitation is the cornerstone of initial management and must be aggressive:

• Administer isotonic crystalloids or albumin with boluses up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension and improve perfusion 1
• Begin peripheral inotropic support for patients unresponsive to fluid resuscitation until central venous access can be obtained 1
• For shock with low cardiac index and low blood pressure, add norepinephrine to epinephrine to increase diastolic blood pressure and systemic vascular resistance 1
• Provide respiratory support starting with face mask oxygen or high-flow nasal cannula oxygen for respiratory distress and hypoxemia 1

Antibiotic Therapy

The antibiotic regimen differs based on the causative organism:

For Streptococcal TSS:

• Combine clindamycin (600-900 mg IV every 8 hours) plus penicillin 1, 2
• Clindamycin is essential because it suppresses streptococcal toxin and cytokine production, which is crucial in managing the toxin-mediated effects 2
• Clindamycin has demonstrated superior efficacy compared to β-lactam antibiotics alone in animal models and observational studies 2
• Penicillin must be added because of potential clindamycin resistance in group A streptococci 2

For Staphylococcal TSS:

• Use vancomycin (30-60 mg/kg/day IV in 2-4 divided doses) in MRSA-prevalent areas 2
• For children, administer IV vancomycin 15 mg/kg/dose every 6 hours for serious or invasive disease 2
• Consider targeting higher trough concentrations (15-20 μg/mL) in severe infections 2
• Alternative agents for penicillin allergies include linezolid, quinupristin/dalfopristin, or daptomycin 2

Critical Timing:

• Obtain blood cultures before antibiotics when possible, but do not delay antibiotic administration beyond 1 hour of identifying severe sepsis 1
• Continue antimicrobial therapy until repeated operative procedures are no longer needed, the patient demonstrates obvious clinical improvement, and fever has been absent for 48-72 hours 2

Source Control

Early and aggressive source control is paramount and directly impacts mortality:

• Perform urgent surgical debridement for necrotizing fasciitis, gangrenous myonecrosis, or any necrotic tissue 3, 1
• Drain empyema and abscesses immediately 1
• Repair perforated viscus with peritoneal washout 1
• Remove any foreign bodies, including tampons, wound packing, or surgical materials 4, 5
• Do not delay surgical intervention when necrotizing infection is confirmed or suspected 2

Adjunctive Therapies

Consider intravenous immunoglobulin (IVIG) in refractory cases, though evidence is mixed:

• IVIG may be beneficial in streptococcal toxic shock syndrome with refractory hypotension 3, 1
• Dosing: 25 g/day for three consecutive days 3
• The evidence shows conflicting results: one small RCT showed non-significant mortality benefit with significant improvement in organ failure scores at days 2-3, while a large retrospective study and Cochrane review found no mortality benefit 3
• Given the mixed evidence, reserve IVIG for patients with GAS-related TSS who remain refractory to standard therapy 3, 2

Hydrocortisone for adrenal insufficiency:

• Administer timely hydrocortisone therapy in children with fluid-refractory, catecholamine-resistant shock and suspected or proven adrenal insufficiency 1

Management of Refractory Shock

When shock persists despite standard therapy, systematically evaluate and correct reversible causes:

• Rule out pericardial effusion, pneumothorax, hypoadrenalism, hypothyroidism, ongoing blood loss, increased intra-abdominal pressure, and inadequate source control 1
• Consider ECMO for refractory pediatric septic shock and respiratory failure when other measures fail 1

Common Pitfalls to Avoid

Several critical errors can worsen outcomes:

• Never use β-lactam antibiotics alone for streptococcal TSS - clindamycin must always be included for toxin suppression 2
• Do not delay antibiotic administration - empiric antimicrobials must be given within 1 hour 1, 2
• Do not underestimate the need for surgical debridement - inadequate source control is a major cause of treatment failure 2
• Do not transfer patients for adjunctive therapies like hyperbaric oxygen if it delays standard care - standard treatment takes priority 3
• Do not stop antibiotics prematurely - continue until no further surgical procedures are needed and the patient has been afebrile for 48-72 hours 2