What is the treatment for toxic shock syndrome?

Treatment for Toxic Shock Syndrome

Toxic shock syndrome requires immediate aggressive treatment with fluid resuscitation, source control, combination antibiotic therapy including clindamycin for toxin suppression, and hemodynamic support—all initiated within the first hour of recognition. 1

Immediate Resuscitation (Within 1 Hour)

Fluid Resuscitation

• Administer isotonic crystalloids or albumin in boluses of 20 mL/kg over 5-10 minutes, titrated to reverse hypotension and improve perfusion 1
• Large volumes may be necessary due to capillary leak and fluid shift into interstitial space 2
• Obtain blood cultures before antibiotics when possible, but do not delay antimicrobial therapy 1

Respiratory Support

• Start with face mask oxygen or high-flow nasal cannula oxygen for respiratory distress and hypoxemia 1

Antibiotic Therapy (Within 1 Hour)

For Streptococcal TSS

• Clindamycin (600-900 mg IV every 8 hours) PLUS penicillin is the recommended combination 1
• Clindamycin is essential because it suppresses toxin production and modulates cytokine release—mechanisms that beta-lactams alone cannot achieve 1, 3

For Staphylococcal TSS

• Use a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) PLUS clindamycin or linezolid 4
• Clindamycin inhibits bacterial protein synthesis and suppresses toxin production 3

Empiric Therapy When Organism Unknown

• Vancomycin PLUS piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem provides broad-spectrum coverage until the causative organism is identified 3

Source Control (Urgent—Do Not Delay)

Early and aggressive source control is paramount and must not be delayed 1, 3

Surgical Intervention Required For:

• Necrotizing fasciitis 1, 3
• Gangrenous myonecrosis 1, 3
• Necrotizing pneumonia 1
• Empyema and abscesses requiring drainage 1
• Perforated viscus (requires repair and peritoneal washout) 1

Non-Surgical Source Control:

• Remove tampons or vaginal devices immediately 2
• Drain and debride surgical wound infections or soft tissue abscesses 4, 2

Hemodynamic Support

For Fluid-Refractory Hypotension

• Begin peripheral inotropic support until central venous access is 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, 3

For Shock with High Cardiac Index and Low Systemic Vascular Resistance

• Titrate norepinephrine with fluid resuscitation 5
• If hypotension persists, consider low-dose vasopressin, angiotensin, or terlipressin with cardiac output/ScvO2 monitoring 5

Adjunctive Therapies

Intravenous Immunoglobulin (IVIG)

• Consider IVIG in refractory toxic shock syndrome, though efficacy is not definitively established 1, 3
• IVIG contains superantigen-neutralizing antibodies that may block toxin effects 6

Corticosteroids

• Administer timely hydrocortisone therapy in fluid-refractory, catecholamine-resistant shock with suspected or proven adrenal insufficiency 1, 3

Management of Refractory Shock

Rule out and correct potentially reversible causes: 1, 3

• Pericardial effusion (requires pericardiocentesis) 5, 1
• Pneumothorax (requires thoracentesis) 5, 1
• Hypoadrenalism (requires adrenal hormone replacement) 5, 1
• Hypothyroidism (requires thyroid hormone replacement) 5, 1
• Ongoing blood loss (requires blood replacement/hemostasis) 5, 1
• Increased intra-abdominal pressure (requires peritoneal catheter or abdominal release) 5, 1
• Necrotic tissue (requires nidus removal) 5, 1

ECMO Consideration

• Consider ECMO for refractory pediatric septic shock when other measures fail, though expected survival is approximately 50% 5, 1

Common Pitfalls to Avoid

• Do not delay surgical debridement for any reason—early source control is more critical than any other intervention 1, 3
• Do not use beta-lactam antibiotics alone—clindamycin must be included for toxin suppression regardless of the causative organism 1, 3
• Do not underestimate fluid requirements—patients typically need massive volume resuscitation due to capillary leak 2
• Do not miss occult sources of infection—thoroughly examine for surgical wounds, soft tissue infections, retained foreign bodies, or postpartum/postabortion sources 4

Duration of Therapy

• Continue antibiotics until clinical resolution of infection and normalization of inflammatory markers 3
• Reassess antimicrobial regimen daily for potential de-escalation once pathogen is identified and sensitivities are established 3
• Typical treatment duration is 7-10 days for most serious infections associated with sepsis 3