Treatment of Streptococcal Toxic Shock Syndrome

Introduction to Treatment

• The World Health Organization recommends considering IVIG in patients with streptococcal TSS, with evidence suggesting potential benefits in refractory cases 1
• A typical dose of IVIG is 25 g/day for three consecutive days, as suggested by the Infectious Diseases Society of America 1

Fluid Resuscitation and Cardiovascular Support

• Administer crystalloids or albumin in boluses of up to 20 mL/kg over 5-10 minutes, titrated to reverse hypotension, increase urine output, and normalize peripheral perfusion, as recommended by the Critical Care Medicine society and the American College of Critical Care Medicine 2
• Begin peripheral inotropic support until central venous access can be attained, as suggested by the Critical Care Medicine society 2
• Provide aggressive fluid resuscitation to maintain adequate blood pressure and organ perfusion, as recommended by the Society of Critical Care Medicine 2
• Use vasopressors if fluid resuscitation fails to restore blood pressure, as recommended by the Society of Critical Care Medicine 2
• Avoid overaggressive fluid resuscitation, which can cause pulmonary, cutaneous, and intestinal edema, as cautioned by the British Journal of Dermatology society and the British Association of Dermatologists 3

Respiratory Support

• Start with face mask oxygen or high-flow nasal cannula for respiratory distress and hypoxemia, as recommended by the Critical Care Medicine society 2
• Consider mechanical ventilation if needed, after appropriate cardiovascular resuscitation, as suggested by the Critical Care Medicine society 2
• Consider extracorporeal membrane oxygenation (ECMO) for refractory septic shock and respiratory failure, as suggested by the Critical Care Medicine society 2

Antibiotic Therapy

• Initiate antibiotics within 1 hour of identifying severe sepsis/TSS, as recommended by the Critical Care Medicine society 2
• Use clindamycin (600-900 mg/kg every 8 hours IV) to suppress toxin production in patients with toxic shock syndrome, with a strength of evidence based on clinical experience and case reports, as recommended by the Infectious Diseases Society of America 4, 5
• For staphylococcal TSS, use clindamycin plus antistaphylococcal penicillin (nafcillin/oxacillin) or vancomycin for MRSA, as recommended by the Infectious Diseases Society of America and the Society of Critical Care Medicine 5, 2
• For streptococcal TSS, use clindamycin plus penicillin, as recommended by the Infectious Diseases Society of America and the Society of Critical Care Medicine 5, 2
• Avoid delaying antimicrobial therapy while waiting for culture results, as warned by the Society of Critical Care Medicine 2

Source Control and Wound Care

• Early and aggressive source control is critical, as emphasized by the Critical Care Medicine society 2
• Aggressive surgical debridement is recommended in cases of necrotizing infections, with the goal of removing the source of infection and promoting healing, based on the principles of critical care medicine 2
• Adequate drainage of abscesses or collections is necessary to control the infectious source, according to the guidelines of infectious diseases treatment 4
• Handle skin with extreme care to minimize shearing forces and prevent further detachment, as recommended by the British Association of Dermatologists 3
• Gently cleanse wounds using warmed sterile water, saline, or diluted chlorhexidine, as suggested by the British Journal of Dermatology society and the British Association of Dermatologists 3
• Apply a greasy emollient over the entire epidermis, including denuded areas, as recommended by the British Association of Dermatologists 3
• Leave detached epidermis in place to act as a biological dressing, as suggested by the British Association of Dermatologists 3
• Decompress blisters by piercing and expressing or aspirating fluid, as recommended by the British Association of Dermatologists 3
• Apply non-adherent dressings directly to denuded dermis, as recommended by the British Association of Dermatologists 3
• Use secondary foam dressings to collect exudate, as suggested by the British Association of Dermatologists 3
• Consider silver-containing products for areas with signs of infection, as recommended by the British Journal of Dermatology society and the British Association of Dermatologists 3
• Avoid aggressive debridement of detached skin, which may worsen the condition, as warned by the British Association of Dermatologists 3
• Avoid using adhesive dressings that can further damage fragile skin, as warned by the British Association of Dermatologists 3

Adjunctive Therapy

• Consider hydrocortisone in cases of refractory shock with suspected adrenal insufficiency, as suggested by the Critical Care Medicine society 2
• Timely hydrocortisone therapy in fluid-refractory, catecholamine-resistant shock, as recommended by the Critical Care Medicine society 2
• Consider ECMO for refractory septic shock and respiratory failure, as suggested by the Critical Care Medicine society 2
• The use of intravenous immunoglobulin (IGIV) may be considered in refractory cases of toxic shock syndrome, although the evidence is not conclusive, based on the principles of critical care medicine 2

Monitoring and Prevention of Complications

• Monitor for signs of systemic infection, including confusion, hypotension, reduced urine output, and reduced oxygen saturation, as recommended by the British Journal of Dermatology society and the British Association of Dermatologists 3
• Carefully monitor electrolytes, renal, and hepatic function, as recommended by the Society of Critical Care Medicine 2
• Monitor for secondary infection of denuded skin areas, as recommended by the British Association of Dermatologists 3
• Assess severity using the SCORTEN score to predict mortality, as suggested by the British Association of Dermatologists 3
• Evaluate for and reverse pneumothorax, pericardial tamponade, endocrine emergencies in refractory shock, as suggested by the Critical Care Medicine society 2
• Evaluate for and reverse secondary infections of denuded skin areas, as recommended by the British Journal of Dermatology society and the British Association of Dermatologists 3

Prevention of Common Pitfalls

• Avoid indiscriminate prophylactic antibiotics, which may increase skin colonization, particularly with Candida albicans, as warned by the British Journal of Dermatology society and the British Association of Dermatologists 3
• Avoid overaggressive fluid resuscitation, which can cause pulmonary, cutaneous, and intestinal edema, as cautioned by the British Journal of Dermatology society and the British Association of Dermatologists 3
• Avoid delaying antimicrobial therapy while waiting for culture results, as warned by the Society of Critical Care Medicine 2
• Avoid aggressive debridement of detached skin, which may worsen the condition, as warned by the British Association of Dermatologists 3
• Avoid using adhesive dressings that can further damage fragile skin, as warned by the British Association of Dermatologists 3
• Failure to recognize and control the source of infection, as warned by the Infectious Diseases Society of America 5