Synopsis
Recognise superantigen-mediated shock, resuscitate organ failure, remove the toxin-producing focus and combine bactericidal therapy with specialist-directed toxin suppression.
- Toxic shock syndrome is a superantigen-driven clinical syndrome of fever, hypotension, rash or soft-tissue focus and multiorgan dysfunction.
- Staphylococcal disease often has diffuse sunburn-like erythroderma, mucosal hyperaemia, vomiting and later palm and sole desquamation; blood cultures may be negative.
- Streptococcal toxic shock commonly accompanies bacteraemia, severe focal pain, necrotising fasciitis or myositis and has high mortality.
Key red flags
Hypotension, rising lactate, confusion, oliguria or hypoxaemia indicates established shock and organ failure.
Fever, hypotension, generalised sunburn-like erythema and conjunctival, oral or vaginal hyperaemia suggests staphylococcal toxic shock.
Investigation priorities
Identify invasive streptococcal or staphylococcal bacteraemia before antibiotics.
Management branches
Fever, hypotension and compatible rash, focal pain or multiorgan dysfunction makes toxic shock plausible.
- Use ABCDE, provide oxygen when indicated, establish access, measure lactate and glucose, take blood cultures and begin physiology-guided crystalloid resuscitation.
- Start the local severe sepsis and toxic-shock intravenous regimen immediately, including high-dose clindamycin when streptococcal or staphylococcal toxin disease is suspected.
Key medicines
Benzylpenicillin plus clindamycin for GASGive benzylpenicillin 2.4 g intravenously every four hours plus clindamycin 1.2 g intravenously every six hours for confirmed susceptible group A streptococcal toxic shock.
Flucloxacillin plus clindamycin for MSSAGive flucloxacillin 2 g intravenously every four to six hours plus clindamycin 1.2 g intravenously every six hours when directed for susceptible staphylococcal toxic shock.