How should I manage a patient who left a tampon in for an extended period, including evaluation for toxic‑shock syndrome and appropriate treatment?

Management of Retained Tampon with Evaluation for Toxic Shock Syndrome

Remove the tampon immediately, obtain vaginal cultures for Staphylococcus aureus and TSS toxin-1, and initiate aggressive supportive care with close monitoring for signs of toxic shock syndrome over the next 48-72 hours. 1, 2

Immediate Assessment and Intervention

Initial Evaluation

• Remove the retained tampon immediately upon presentation, as this is the primary source control measure 3, 4
• Perform a thorough pelvic examination to assess for purulent vaginal discharge, which may indicate staphylococcal infection 1
• Obtain vaginal/cervical cultures specifically for Staphylococcus aureus and TSS toxin-1 before initiating antibiotics 5, 1

Clinical Signs Requiring Immediate Escalation

Monitor for the following features that define toxic shock syndrome:

• Fever ≥38.9°C (102°F) 5
• Hypotension (systolic BP <90 mmHg or orthostatic dizziness/syncope) 3, 5
• Diffuse erythematous macular rash (may resemble scarlet fever) 3, 2
• Mucous membrane inflammation (pharyngitis, conjunctival injection, vaginal hyperemia) 5
• Gastrointestinal symptoms (vomiting, diarrhea) 3, 2
• Myalgias and malaise 3, 2

Laboratory Assessment

If any systemic symptoms are present, obtain:

• Complete blood count (looking for thrombocytopenia, elevated WBC) 1, 2
• Comprehensive metabolic panel (assessing for renal dysfunction, elevated liver enzymes) 2
• Lactate level (elevated in shock states) 1
• Coagulation studies (may show abnormalities) 2
• Blood cultures (bacteremia occurs in minority of cases but carries high mortality) 5

Treatment Algorithm Based on Clinical Presentation

Asymptomatic Patient (No Systemic Signs)

• Remove tampon and observe for 48-72 hours 3
• Provide clear return precautions for fever, rash, hypotension, or gastrointestinal symptoms 4
• No antibiotics are indicated if the patient is completely asymptomatic 3
• Counsel patient to avoid tampon use indefinitely to prevent recurrence 4

Patient with Mild Systemic Symptoms (Fever, Malaise) Without Hypotension

• Remove tampon and obtain cultures 1
• Consider empiric antibiotics if clinical suspicion is moderate:
  • Vancomycin 30-60 mg/kg/day IV in 2-4 divided doses (in MRSA-prevalent areas) 6
  • PLUS clindamycin 600-900 mg IV every 8 hours (to suppress toxin production) 6, 7
• Admit for observation and serial vital signs 2
• Continue antibiotics for 7-10 days if cultures confirm S. aureus 3

Patient with Toxic Shock Syndrome (Hypotension and Multisystem Involvement)

This is a medical emergency requiring immediate intensive care:

Hemodynamic Resuscitation

• Administer empiric antimicrobials within 1 hour of identifying severe sepsis 7
• Aggressive fluid resuscitation with isotonic crystalloids or albumin: boluses up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension 7
• Large volumes may be necessary (patients are profoundly hypovolemic due to capillary leak) 3
• If unresponsive to fluids, begin peripheral inotropic support until central venous access obtained 7
• For persistent shock, add norepinephrine to epinephrine to increase diastolic BP and systemic vascular resistance 7

Antibiotic Therapy

For staphylococcal TSS (most common with retained tampons):

• Vancomycin 30-60 mg/kg/day IV in 2-4 divided doses (in MRSA-prevalent areas) 6
• PLUS clindamycin 600-900 mg IV every 8 hours 6, 7
  • Clindamycin is essential because it suppresses bacterial toxin production and modulates cytokine (TNF) production, which β-lactams cannot do 6
  • This combination is superior to β-lactam antibiotics alone 6

Alternative agents for penicillin-allergic patients:

• Vancomycin, linezolid, quinupristin/dalfopristin, or daptomycin 6

Duration of Therapy

• Continue antimicrobials until fever has been absent for 48-72 hours and obvious clinical improvement is demonstrated 6
• Typical course is 7-10 days but may be extended based on clinical response 3

Adjunctive Therapies

• Consider intravenous immunoglobulin (IVIG) in refractory toxic shock syndrome, though efficacy is not definitively established 6, 7
• Evaluate for and reverse pneumothorax, pericardial tamponade, or endocrine emergencies in patients with refractory shock 7

Critical Pitfalls to Avoid

• Do not delay tampon removal while awaiting laboratory results or specialist consultation 3, 1
• Do not use β-lactam antibiotics alone for suspected TSS—clindamycin must be included for toxin suppression 6
• Do not dismiss mild symptoms in a patient with recent tampon use—TSS can progress rapidly from nonspecific viral-like illness to shock within hours 3, 4
• Do not rely solely on diagnostic criteria to make the diagnosis—specific clinical situations (recent tampon use with fever and rash) should trigger empiric treatment 4, 2
• Do not underestimate fluid requirements—patients may need massive volume resuscitation due to capillary leak syndrome 3
• Always perform a pelvic examination in young females presenting with unexplained shock 1

Patient Counseling and Follow-up

• Advise permanent discontinuation of tampon use to prevent recurrence (recurrence rate is significant without this intervention) 4
• Educate about early warning signs of TSS for future vigilance 4
• Arrange follow-up within 1-2 weeks to ensure complete resolution and review culture results 2