Treatment of streptococcal toxic shock syndrome
- Dennis L Stevens, MD, PhD
Dennis L Stevens, MD, PhD
- Professor of Medicine
- University of Washington School of Medicine
Streptococcal toxic shock syndrome (TSS) is a clinical illness characterized by shock and multiorgan failure; it occurs as a result of capillary leak and tissue damage due to release of inflammatory cytokines induced by streptococcal toxins.
Streptococcal TSS occurs most frequently in the setting of infection due to group A Streptococcus (GAS; Streptococcus pyogenes). GAS typically causes pharyngitis or skin and soft tissue infection; these are generally responsive to appropriate antibiotic therapy . Less commonly, GAS causes invasive disease such as necrotizing infection of the skin and fascia, gangrenous myositis, bacteremia, or pneumonia . Invasive disease is complicated by TSS in approximately one-third of cases [3-5].
The treatment of streptococcal toxic shock syndrome will be reviewed here. The epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock syndrome are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock syndrome".)
Management of streptococcal toxic shock syndrome (TSS) includes treatment of septic shock and associated complications, surgical debridement of infection (if feasible), and antimicrobial therapy (table 1). Such cases frequently require coordinated care from a team, including individuals with clinical expertise in critical care, surgery, and infectious disease.
Treatment of septic shock — Streptococcal sepsis leads to diffuse capillary leak and intractable hypotension. Therefore, large quantities of intravenous (IV) fluids may be necessary to maintain perfusion (up to 10 to 20 L/day); vasopressors may also be required. The approach to management of septic shock is discussed separately. (See "Evaluation and management of suspected sepsis and septic shock in adults".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996; 334:240.
- Darenberg J, Luca-Harari B, Jasir A, et al. Molecular and clinical characteristics of invasive group A streptococcal infection in Sweden. Clin Infect Dis 2007; 45:450.
- Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989; 321:1.
- Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med 1996; 335:547.
- Wong CJ, Stevens DL. Serious group a streptococcal infections. Med Clin North Am 2013; 97:721.
- Group A streptococcal infections and a toxic shock-like syndrome. N Engl J Med 1989; 321:1545.
- Martin PR, Høiby EA. Streptococcal serogroup A epidemic in Norway 1987-1988. Scand J Infect Dis 1990; 22:421.
- Hríbalová V. Streptococcus pyogenes and the toxic shock syndrome. Ann Intern Med 1988; 108:772.
- Adams EM, Gudmundsson S, Yocum DE, et al. Streptococcal myositis. Arch Intern Med 1985; 145:1020.
- Stevens DL. Invasive group A streptococcus infections. Clin Infect Dis 1992; 14:2.
- Köhler W. Streptococcal toxic shock syndrome. Zentralbl Bakteriol 1990; 272:257.
- EAGLE H. Experimental approach to the problem of treatment failure with penicillin. I. Group A streptococcal infection in mice. Am J Med 1952; 13:389.
- Stevens DL, Gibbons AE, Bergstrom R, Winn V. The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 1988; 158:23.
- Stevens DL, Bryant AE, Yan S. Invasive group A streptococcal infection: New concepts in antibiotic treatment. Int J Antimicrob Agents 1994; 4:297.
- Stevens DL, Yan S, Bryant AE. Penicillin-binding protein expression at different growth stages determines penicillin efficacy in vitro and in vivo: an explanation for the inoculum effect. J Infect Dis 1993; 167:1401.
- Yan S, Mendelman PM, Stevens DL. The in vitro antibacterial activity of ceftriaxone against Streptococcus pyogenes is unrelated to penicillin-binding protein 4. FEMS Microbiol Lett 1993; 110:313.
- Zimbelman J, Palmer A, Todd J. Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J 1999; 18:1096.
- Carapetis JR, Jacoby P, Carville K, et al. Effectiveness of clindamycin and intravenous immunoglobulin, and risk of disease in contacts, in invasive group a streptococcal infections. Clin Infect Dis 2014; 59:358.
- Yan S, Bohach GA, Stevens DL. Persistent acylation of high-molecular-weight penicillin-binding proteins by penicillin induces the postantibiotic effect in Streptococcus pyogenes. J Infect Dis 1994; 170:609.
- Stevens DL, Maier KA, Mitten JE. Effect of antibiotics on toxin production and viability of Clostridium perfringens. Antimicrob Agents Chemother 1987; 31:213.
- Gemmell CG, Peterson PK, Schmeling D, et al. Potentiation of opsonization and phagocytosis of Streptococcus pyogenes following growth in the presence of clindamycin. J Clin Invest 1981; 67:1249.
- Mascini EM, Jansze M, Schouls LM, et al. Penicillin and clindamycin differentially inhibit the production of pyrogenic exotoxins A and B by group A streptococci. Int J Antimicrob Agents 2001; 18:395.
- Richter SS, Heilmann KP, Beekmann SE, et al. Macrolide-resistant Streptococcus pyogenes in the United States, 2002-2003. Clin Infect Dis 2005; 41:599.
- Gooskens J, Neeling AJ, Willems RJ, et al. Streptococcal toxic shock syndrome by an iMLS resistant M type 77 Streptococcus pyogenes in the Netherlands. Scand J Infect Dis 2005; 37:85.
- Kaul R, McGeer A, Norrby-Teglund A, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis 1999; 28:800.
- Stegmayr B, Björck S, Holm S, et al. Septic shock induced by group A streptococcal infection: clinical and therapeutic aspects. Scand J Infect Dis 1992; 24:589.
- Barry W, Hudgins L, Donta ST, Pesanti EL. Intravenous immunoglobulin therapy for toxic shock syndrome. JAMA 1992; 267:3315.
- Yong JM. Necrotising fasciitis. Lancet 1994; 343:1427.
- Norrby-Teglund A, Muller MP, Mcgeer A, et al. Successful management of severe group A streptococcal soft tissue infections using an aggressive medical regimen including intravenous polyspecific immunoglobulin together with a conservative surgical approach. Scand J Infect Dis 2005; 37:166.
- Darenberg J, Ihendyane N, Sjölin J, et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003; 37:333.
- Linnér A, Darenberg J, Sjölin J, et al. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Clin Infect Dis 2014; 59:851.
- Shah SS, Hall M, Srivastava R, et al. Intravenous immunoglobulin in children with streptococcal toxic shock syndrome. Clin Infect Dis 2009; 49:1369.
- Kadri SS, Swihart BJ, Bonne SL, et al. Impact of Intravenous Immunoglobulin on Survival in Necrotizing Fasciitis With Vasopressor-Dependent Shock: A Propensity Score-Matched Analysis From 130 US Hospitals. Clin Infect Dis 2017; 64:877.
- Norrby-Teglund A, Kaul R, Low DE, et al. Plasma from patients with severe invasive group A streptococcal infections treated with normal polyspecific IgG inhibits streptococcal superantigen-induced T cell proliferation and cytokine production. J Immunol 1996; 156:3057.
- Norrby-Teglund A, Kaul R, Low DE, et al. Evidence for the presence of streptococcal-superantigen-neutralizing antibodies in normal polyspecific immunoglobulin G. Infect Immun 1996; 64:5395.
- Darenberg J, Söderquist B, Normark BH, Norrby-Teglund A. Differences in potency of intravenous polyspecific immunoglobulin G against streptococcal and staphylococcal superantigens: implications for therapy of toxic shock syndrome. Clin Infect Dis 2004; 38:836.
- Shimozato T, Iwata M, Tamura N. Suppression of tumor necrosis factor alpha production by a human immunoglobulin preparation for intravenous use. Infect Immun 1990; 58:1384.
- Achiron A, Margalit R, Hershkoviz R, et al. Intravenous immunoglobulin treatment of experimental T cell-mediated autoimmune disease. Upregulation of T cell proliferation and downregulation of tumor necrosis factor alpha secretion. J Clin Invest 1994; 93:600.
- Holm SE, Norrby A, Bergholm AM, Norgren M. Aspects of pathogenesis of serious group A streptococcal infections in Sweden, 1988-1989. J Infect Dis 1992; 166:31.
- Schrage B, Duan G, Yang LP, et al. Different preparations of intravenous immunoglobulin vary in their efficacy to neutralize streptococcal superantigens: implications for treatment of streptococcal toxic shock syndrome. Clin Infect Dis 2006; 43:743.
- Stevens DL, Bryant AE, Hackett SP, et al. Group A streptococcal bacteremia: the role of tumor necrosis factor in shock and organ failure. J Infect Dis 1996; 173:619.
- Ekelund K, Skinhøj P, Madsen J, Konradsen HB. Reemergence of emm1 and a changed superantigen profile for group A streptococci causing invasive infections: results from a nationwide study. J Clin Microbiol 2005; 43:1789.
- Demers B, Simor AE, Vellend H, et al. Severe invasive group A streptococcal infections in Ontario, Canada: 1987-1991. Clin Infect Dis 1993; 16:792.
- Hasegawa T, Hashikawa SN, Nakamura T, et al. Factors determining prognosis in streptococcal toxic shock-like syndrome: results of a nationwide investigation in Japan. Microbes Infect 2004; 6:1073.
- Patel RA, Binns HJ, Shulman ST. Reduction in pediatric hospitalizations for varicella-related invasive group A streptococcal infections in the varicella vaccine era. J Pediatr 2004; 144:68.
- Prevention of Invasive Group A Streptococcal Infections Workshop Participants. Prevention of invasive group A streptococcal disease among household contacts of case patients and among postpartum and postsurgical patients: recommendations from the Centers for Disease Control and Prevention. Clin Infect Dis 2002; 35:950.
- Sablier F, Slaouti T, Drèze PA, et al. Nosocomial transmission of necrotising fasciitis. Lancet 2010; 375:1052.
- Treatment of septic shock
- Surgical debridement
- Antibiotic therapy
- - General principles
- - Antibiotic regimens
- Empiric therapy
- Tailored therapy
- - Duration of therapy
- Adjunctive therapy
- - Intravenous immune globulin
- - Other therapies
- MANAGEMENT OF HOUSEHOLD CONTACTS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS