infectious diseases
Toxic Shock Syndrome (TSS)
Treatment of Toxic Shock Syndrome
Local measures (eg, decontamination, debridement) Fluid resuscitation and circulatory support Empiric antibiotic therapy (eg,clindamycinorlinezolidplusvancomycin,daptomycin,linezolid, orceftaroline) pending culture results Patients suspected of having TSS should be hospitalized immediately and treated intensively. Tampons, diaphragms, and other foreign bodies should be removed at once. Suspected primary sites should be decontaminated thoroughly. Decontamination includes Reinspection and irrigation of surgical wounds, even if they appear healthy Repeated debridement of devitalized tissues Irrigation of potential naturally colonized sites (sinuses, vagina) Fluids and electrolytes are replaced to prevent or treat hypovolemia, hypotension, and shock. Because fluid loss into tissues can occur throughout the body (because of systemic capillary leak syndrome and hypoalbuminemia), shock may be profound and resistant. Aggressive fluid resuscitation and circulatory, ventilatory, and/or hemodialysis support are sometimes required. Obvious infections should be treated with antibiotics (for indications and doses, see table). Pending culture results,clindamycinorlinezolid(to suppress toxin production) plusvancomycin,daptomycin,linezolid, orceftaroline—empiric choices that cover the most likely etiologic organisms—should be used. If a pathogen is isolated on culture, the antibiotic regimen is adjusted as needed, as for the following: For group A streptococci:Clindamycinplus a beta-lactam For methicillin-susceptibleS. aureus(MSSA):Clindamycinplusoxacillinornafcillin For methicillin-resistantStaphylococcus aureus(MRSA):Vancomycinordaptomycinplusclindamycinorlinezolid, depending on the susceptibility Antibiotics given during the acute illness may eradicate pathogen foci and prevent recurrences. Passive immunization to TSS toxins with IV immune globulin (2 g/kg, followed by 0.4 g/kg daily for up to 5 days) has been helpful in severe cases of both types of TSS and lasts for weeks, but the disease may not induce active immunity, so recurrences are possible. If a test for seroconversion of the serum antibody responses to TSST-1 in acute- and convalescent-phase paired sera is negative, women who have had staphylococcal TSS should probably refrain from using tampons and menstrual cups, cervical caps, contraceptive sponges, intrauterine devices, diaphragms, and pessaries. Advising all women, regardless of TSST-1 antibody status, to change tampons frequently or use napkins instead and to avoid hyperabsorbent tampons seems prudent. 