How should TSS be Treated?
Treatment involves several key components:
1) Identification and decontamination of the site of toxin production: Drain or debride the lesion, remove foreign material, and irrigate copiously. Recent surgical wounds should be explored and irrigated even when signs of inflammation are absent.
2) Aggressive fluid resuscitation: Loss of fluid into the extravascular compartment can be very substantial. Maintenance of cardiac filling pressures is critical in order to prevent end organ damage. Adult patients with TSS have required up to 10 L of fluid in the first 24 hr.
3) Administration of antistaphylococcal antibiotics: Semisynthetic penicillins have been widely used for TSS. Growing evidence, however, suggests that the protein synthesis inhibitor clindamycin is more efficacious in this illness. Accordingly, the author recommends treating suspected TSS patients with clindamycin (900 mg i.v. every 8 hours for adults; 13 mg/kg i.v. every 8 hours for children), either alone or in combination with a cell wall active agent (semisynthetic penicillin or vancomycin). If the diagnosis of TSS is initially uncertain, broader empiric coverage is appropriate.
4) General supportive care: Intensive care monitoring is often indicated. Replete calcium and magnesium; provide ventilatory, pressor, and inotropic support; manage rhabdomyolysis, renal dysfunction, and / or coagulopathy.
5) Administration of pooled human immunoglobin: This should be reserved for refractory cases or cases associated with an undrainable focus of infection. All commercial immunoglobulin preparations contain high levels of anti-TSST-1 antibody. A single infusion of 400 mg/kg i.v. will generate a protective titre in a nonimmune patient.
Written by Dr. Colin Michie MA FRCPCH FLS
Treatment of TSS includes the administration of antibiotics that kill S. aureus and decrease production of the toxin or toxins that are causing the illness. As the incidence of community-acquired infection with MRSA increases, it will become important to consider the possibility that MRSA is responsible for a case of TSS, especially if a patient does not respond to treatment as expected. Physicians caring for patients with TSS, especially severe cases or in geographic areas where there is a high rate of infection with MRSA, should consider antibiotics that are effective against MSRA.