eMedicine Specialties > Dermatology > Bacterial Infections
Toxic Shock Syndrome: Treatment & Medication
Updated: Jul 15, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment of TSS includes supportive therapy, including hydration, vasopressors, penicillinase-resistant antibiotics, and drainage of infected sites. In vitro studies have suggested that sublethal concentrations of silver sulfadiazine cream lead to increased toxin production by S aureus; therefore, mupirocin ointment or povidone iodine solution may be better choices for topical care of infected sites. Washing with chlorhexidine gluconate may be beneficial in eradicating MRSA. Drotrecogin alfa has been reported to be beneficial in treating MRSA TSS.3
Management of STSS is similar to that of TSS. Supportive therapy, vasopressors, and antibiotics are the cornerstones of treatment. The increasingly reported clinical resistance of streptococci to penicillin G, as well as the difficulty in being able to distinguish STSS from TSS in some cases, suggests the need for adequate antimicrobial coverage for both staphylococci and penicillin-resistant streptococci. Consider clindamycin, erythromycin, cephalosporins, or other agents as deemed appropriate by clinical presentation and culture results. Intravenous immunoglobulin (IVIG) has been reported to be dramatically effective in STSS but is not yet in widespread use.4
Consultations
- Infectious disease specialist - To determine appropriate antibiotic coverage
- Critical care specialist - To evaluate and treat potential complications
- Dermatologist
Medication
Antibiotics are important in the treatment of TSS. Because distinguishing STSS from TSS may be difficult, adequate antibiotic coverage for both staphylococci and streptococci is suggested until a definitive bacterial pathogen is isolated. Antibiotics should include a parenteral antistaphylococcal/streptococcal semisynthetic penicillin or a first-generation cephalosporin in combination with clindamycin. When MRSA is suspected, vancomycin or linezolid and rifampin may be added to or in place of an antistaphylococcal/streptococcal penicillin or cephalosporin.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Nafcillin (Nafcil, Unipen, Nallpen)
Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Due to thrombophlebitis, particularly in the elderly, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated.
Adult
1-2 g IV q4h
Pediatric
50-200 mg/kg/d IV divided q4-6h
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
To optimize therapy, determine causative organisms and susceptibility; treat for >10 d to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); take cultures after treatment to confirm that infection is eradicated
Clindamycin (Cleocin)
Drug of choice in STSS. Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.
Adult
600-900 mg IV q8h
Pediatric
20-40 mg/kg/d IV divided q6-8h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Cefazolin (Ancef)
Semisynthetic first-generation cephalosporin that exhibits bactericidal activity by inhibiting cell wall synthesis. Active against penicillinase producing S aureus; however, MRSA and GAS are resistant.
Adult
0.5-1.5 g IM/IV q6-8h
Pediatric
25-100 mg/kg IM/IV qd divided q6-8h
Probenecid may decrease excretion; may increase INR when used with warfarin
Documented hypersensitivity to the cephalosporin group of antibiotics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dosage in renal insufficiency or failure; seizures may occur in patients with renal impairment administered high doses; caution in patients with a penicillin or beta-lactam allergy; may cause pseudomembranous colitis; may increase prothrombin time
Vancomycin (Vancocin)
Tricyclic glycopeptide antibiotic that exhibits bactericidal effects by inhibiting cell wall and RNA synthesis and by altering bacterial cell membrane permeability; ideally used when MRSA is suspected
Adult
1 gram IV q12h
Pediatric
10 mg/kg IV q6h
Cidofovir is contraindicated; clofarabine, gallium, aminoglycosides and other nephrotoxic drugs may increase nephrotoxicity
Documented hypersensitivity; cidofovir combined with vancomycin may increase risk of nephrotoxicity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dosage in renal insufficiency or failure; may cause nephrotoxicity, ototoxicity, reversible neutropenia, and, rarely thrombocytopenia; red man syndrome erythroderma may occur; oral formulations of vancomycin are not systemically absorbed and should not be used for systemic infections
Linezolid (Zyvox)
Prevents formation of functional 70S initiation complex, which is essential for bacterial translation process. Bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci. Used as alternative in patients allergic to vancomycin and for treatment of vancomycin-resistant enterococci.
Adult
600 mg PO/IV q12h for 10-14 d
Pediatric
Preterm neonate <7 days: 10 mg/kg PO/IV q12h; in cases of suboptimal response, may use 10 mg/kg PO/IV q8h
Term neonates to 12 years: 10 mg/kg PO/IV q8h for 10-14 d
>12 years: Administer as in adults
May cause hypertension when used concomitantly with adrenergic agents including pseudoephedrine, sympathomimetic agents, vasopressor or dopaminergic agents (reduce dose of dopamine or epinephrine if concurrent use required); serotonin syndrome may occur if used concomitantly with serotonergic agents including tricyclic antidepressants, meperidine, dextromethorphan, trazodone, venlafaxine, and selective serotonin reuptake inhibitors; may cause myelosuppression or pseudomembranous colitis inhibitors
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Has mild MAOI properties and has potential to have same interactions as other MAOIs; caution in uncontrolled hypertension, pheochromocytoma, carcinoid syndrome, or untreated hyperthyroidism, and patients who are at increased risk for bleeding, have preexisting thrombocytopenia, receive concomitant medications that may decrease platelet count or function, or who may require >2 wk of therapy (monitor platelet counts); unnecessary use may lead to development of resistance to drug; may cause peripheral or optic neuropathy
More on Toxic Shock Syndrome |
| Overview: Toxic Shock Syndrome |
| Differential Diagnoses & Workup: Toxic Shock Syndrome |
 Treatment & Medication: Toxic Shock Syndrome |
| Follow-up: Toxic Shock Syndrome |
| References |
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References
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Further Reading
Keywords
shock, TSS, STSS, toxic strep, streptococcal toxic shock-like syndrome, streptococcal TSS, Staphylococcus aureus, S aureus
