Toxic shock syndrome caused by staphylococcus (MRSA detected)

Last Updated: 2019-08-26

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Todd et al. 1978.

Toxic-Shock-Syndrome, TSS.

Superantigen-producing staphylococcal disease with scarlatinous exanthema and reduced general condition. In the process, it can lead to shock and multiorgan failure.

  • Incidence: 0.8-3.4/100,000 (2000-2003).
  • At present, a constant incidence can be assumed.
  • Approximately half of all TSS triggered by Staphylococcus are NM-STSS.
  • Initially, the M-STSS was particularly prevalent. Since patients have now been informed about the regular replacement of tampons and changes have also occurred in their production, the rate of "tampon-triggered toxic shock syndromes" has decreased.
  • Non-menstrual-associated, staphylococcal-induced toxic shock syndrome (NM-STSS).
  • Menstruation-associated, staphylococcal-induced toxic shock syndrome (M-STSS).
  • NM-TSS is mainly caused by staphylococci of the skin (wounds, abscesses, boils), in the context of another gynaecological infection (e.g. postpartum), burns, sinusitis, osteomyelitis or arthritis, respiratory infections after influenza infection, enterocolitis and intravenously drug abuse.
  • Staphylococci produce exotoxins such as Toxic Shock Syndrome Toxin-1 (TSST-1) and Staphylococci Enterotoxins B, C, D, E and H. All these toxins are superantigens and can activate a high number of T-lymphocytes, which then release an exceptionally high number of proinflammatory cytokines.
  • As with all infections, the immune system is very important. Patients without TSST-1 neutralizing antibodies are far more likely to develop TSS than other patients.
  • The initial symptoms include fever, pharyngitis, myalgia, diarrhea, vomiting. There is a macular, scarlatinous, generalized exanthema. Palmoplantar may show erythema. After 1-2 weeks desquamation occurs. Without exception, conjunctival hyperemia, pharyngitis and a "strawberry tongue" are visible. In some cases, the symptoms of the CNS can be determined.
  • The hypotension associated with TSS is shown by a prominent exanthema on the trunk, orthostatic dysfunction and a shock with multiorgan failure.
  • Early treatment often leads to less pronounced symptoms.
  • Between the beginning of menstruation and TSS are on average 2-3 days, after operations often only 2 days, but TSS can still occur after 2 months!

 

  • Clinical criteria (United States Centers for Disease Control and Prevention):
  • Fever: Temperature ≥ 38.9°C.
  • Blood pressure: Systolic blood pressure ≤ 90 mmHg (adults), less than 5th percentile for children under 16 years.
  • Skin change: diffuse, macular (scalatiniform) exanthema.
  • Desquamation: 1-2 weeks after onset of the disease, especially palmoplantar.
  • Multi-organ system (participation of ≥ 3 systems).
  • Gastrointestinal: vomiting, diarrhea.
  • Muscular: Myalgia, ≥ 2-fold increased CK.
  • Mucous membrane: Vaginal, oropharyngeal and hyperemia of the subjunctive.
  • Renal: Urea or Creatinine ≥ 2-fold increased.
  • Liver: Bilirubin or transaminases ≥ increased 2-fold.
  • Hematological: < 100'000 platelets.
  • CNS: disorientation, changes of consciousness without focal neurological signs without fever or hypotension.
  • No other germ detection (except possibly Staphylococcus aureus, however the detection of S. aureus is not essential to make the diagnosis).

  • Negative serological test (antibodies are often only determined in special laboratories) for Rocky Mountain Spotted Fever, leptospirosis or measles.
  • Clinic.
  • Bacterial smears (where focus is suspected: neck, vagina, skin lesions, nasal atrium, groin). S. aureus can be isolated from the suspicious focus in 80-90% of cases, but serological detection is only possible in 5% of cases
  • Blood count (anemia, leukocytosis with neutrophilia, thrombocytopenia), coagulation (consumption coagulopathy, prolonged prothrombin time and partial thromboplastin time), creatinine, Urea (renal insufficiency), transaminases, bilirubin (liver insufficiency), creatinine kinase (myalgia), electrolytes (hyponatremia, hypalbuminemia, hypocalcemia, hypophosphatemia),

  • Blood culture (pathogen detection), U status.

  • CNS symptoms (encephalopathy with disorientation, confusion, epileptic seizures, cerebral edema, headache, memory loss, poor concentration): Neurological consil and cerebrospinal puncture.

  • Breathing problems: Thoracic x-ray and, if necessary, internal consil.
  • Exclusion of a vaginal/intrauterine foreign body.

  • Vital parameter monitoring. .
  • The mortality rate is between 1.8-6%, depending on the trigger and study.
  • Women with M-STSS should no longer use tampons. Spirals for contraception should also be avoided.

  • Recurrences occur days to months after the initial manifestation, in patients who have not received sufficient antibiotic treatment, do not produce their own antibodies and where the cause (the infection focus) has not been remedied. 
  • If necessary, transfer to the intensive care unit.
  • Fluid substitution.
  • Blood pressure monitoring.

  • At a body temperature of > 38°C decrease of blood cultures.
  • Eliminate the focus of infection.
  • CAVE: Postoperative wounds can be clinically unremarkable, but still act as a focus of infection.

 

Systemic Therapy

  • Clindamycin has clearly shown itself superior to ampicillin.

  • ex adjuvant therapy
  • Clindamycin intravenously 3x daily 900 mg (adults), 3x 25-40mg/kg/d (children).

    AND
  • Vancomycin i.v. 3x daily 15-20 mg/kg bw, but not more than 2g (adults), 4x daily 10 mg/kg/d (children).

     

    With proven MRSA infection

  • Clindamycin intravenously 3x daily 900 mg (adults), 3x 25-40mg/kg/d (children).

    AND

  • Vancomycin i.v. 3x daily 15-20 mg/kg bw, but not more than 2g (adults), 4x daily 10 mg/kg/d (children).

    OR

  • Linezolid intravenously 2x 600 mg (adults), 2x daily 10 mg/kg bw (children).
  • Alternative: Vancomycin intravenously 3x daily 15-20 mg/kg bw, but not more than 2g (adults), 4x daily 10 mg/kg/d (children).

    AND

  • Linezolid i.v. 2x 600 mg (adults), 2x daily 10 mg/kg bw (children).

     

    In case of skin infection

  • Procutol Skin Wash Lotion
  • Mupirocin ointment 2x daily for 5 days.

     

  • IVIGs can be used for therapy resistance.
  • No more tampons should be used with M-STSS.
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