Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected toxic shock syndrome

1st line – supportive therapies

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INITIAL
|
suspected toxic shock syndrome
1st line – 

supportive therapies

Early and immediate treatment should include aggressive fluid resuscitation, empirical antibiotic therapy, vasopressor support for refractory hypotension, haemodynamics optimisation, source control, and surgical debridement.

Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension. The use of the vasopressor dopamine has been associated with higher mortality and more arrhythmic events compared with noradrenaline administration.[90]​ Intravenous corticosteroids should be administered for patients with ongoing vasopressor requirements or vasopressor-refractory septic shock.[83]​ Consult a specialist for guidance on suitable vasopressor regimens and doses.

Source control is mandatory, including drainage of any existing abscesses and removal of the tampon, if present.

The patient should be promptly transferred to an intensive care unit for treatment.

Plus – empirical antibiotic therapy

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INITIAL
|
suspected toxic shock syndrome
Plus – 

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotics should be initiated empirically before culture reports.

Recommended empirical therapy is clindamycin plus 1 of the following: a carbapenem (i.e., imipenem/cilastatin or meropenem); a penicillin with a beta-lactamase inhibitor (e.g., ticarcillin/clavulanic acid or piperacillin/tazobactam); or vancomycin (in patients with penicillin allergies).

In patients with suspected staphylococcal toxic shock syndrome, clindamycin plus vancomycin is recommended.

Additional antibiotics may be needed for treating superinfections that may occur.

Primary options

clindamycin: 900 mg intravenously every 8 hours

-- AND --

imipenem/cilastatin: 500 mg intravenously every 6 hours

More

or

meropenem: 1 g intravenously every 8 hours

or

ticarcillin/clavulanic acid: 3.1 g intravenously every 4 hours

More

or

piperacillin/tazobactam: 4.5 g intravenously every 6 hours

More

or

vancomycin: 15-20 mg/kg intravenously every 12 hours

Consider – surgical debridement

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INITIAL
|
suspected toxic shock syndrome
Consider – 

surgical debridement

Additional treatment recommended for SOME patients in selected patient group

Early and immediate surgical debridement should be considered in most patients with suspected streptococcal toxic shock syndrome (i.e., those who present with fever, pain, soft-tissue swelling, and/or vesicle and bullae formation) with an appropriate surgical focus of infection.

Aggressive surgical debridement of infected tissue including fascia is imperative and mandatory if a site of potential infection is identified.

Repeated and sequential operative and bedside debridements of infected tissue are often needed, particularly if necrotising fasciitis is present in streptococcal disease.[63]

In addition to surgical debridements, fasciotomy or amputation may be needed to halt the progression of the disease.

ACUTE

confirmed streptococcal toxic shock syndrome

1st line – clindamycin + benzylpenicillin or vancomycin

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ACUTE
|
confirmed streptococcal toxic shock syndrome
1st line – 

clindamycin + benzylpenicillin or vancomycin

Most experts recommend combination therapy with benzylpenicillin plus clindamycin.[95][96]

Vancomycin may be used in place of benzylpenicillin in patients who are allergic to penicillin

Additional antibiotics may be needed for treating superinfections that may occur.

Treatment duration should be individualised, especially if there is a deep-seated infection. If bacteraemic, the patient should be treated for 14 days. Usually treatment is for 14 days after the last positive culture is obtained at surgery.

Primary options

clindamycin: 900 mg intravenously every 8 hours

-- AND --

benzylpenicillin sodium: 1.2 g intravenously every 4 hours

or

vancomycin: 15-20 mg/kg intravenously every 12 hours

Plus – intensive care unit support

Back
ACUTE
|
confirmed streptococcal toxic shock syndrome
Plus – 

intensive care unit support

Treatment recommended for ALL patients in selected patient group

General intensive care preventive measures include stress ulcer prophylaxis with H2 antagonists or proton-pump inhibitors, deep venous thrombosis prophylaxis with heparin or low-molecular weight heparin, compression stockings, and enteral nutrition.[83][91][92]​​​​​ 

The American Diabetes Association recommends a general glucose goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in most critically ill patients with diabetes, preferably by using an insulin infusion protocol; however, more stringent control of blood glucose, in the range of 110-140 mg/dL, may be appropriate in a selected population of critically ill patients (such as critically ill patients undergoing surgery), if that can be achieved without the risk of hypoglycaemia.[93]​ The Surviving Sepsis Campaign recommends the use of validated insulin infusion protocols targeting a blood glucose level of <10 mmol/L (<180 mg/dL).[83]

Patients with evidence of acute respiratory distress syndrome should receive lung-protective ventilation using maximum plateau pressures <30 cm H₂O and permissive hypercapnia to limit pulmonary damage.[94]

Initial supportive therapy such as aggressive fluid resuscitation, vasopressor support for refractory hypotension, haemodynamics optimisation, and surgical debridement initiated before confirmation of the cause must be continued. Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension. The use of the vasopressor dopamine has been associated with higher mortality and more arrhythmic events compared with noradrenaline administration.[90]​ Intravenous corticosteroids should be administered for patients with ongoing vasopressor requirements or vasopressor-refractory septic shock.[83]​ Consult a specialist for guidance on suitable vasopressor regimens and doses.

Source control is mandatory, including drainage of any existing abscesses and removal of the tampon, if present.

Consider – intravenous immunoglobulin (IVIG)

Back
ACUTE
|
confirmed streptococcal toxic shock syndrome
Consider – 

intravenous immunoglobulin (IVIG)

Additional treatment recommended for SOME patients in selected patient group

The addition of IVIG may be considered for the treatment of streptococcal toxic shock syndrome, although data on efficacy are conflicting.[109][110] [111]

Primary options

normal immunoglobulin human: 1 g/kg intravenously on day 1, followed by 0.5 g/kg on days 2 and 3; or 2 g/kg intravenously as a single dose

More

confirmed staphylococcal toxic shock syndrome: methicillin-sensitive

1st line – clindamycin + oxacillin or nafcillin or vancomycin

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ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-sensitive
1st line – 

clindamycin + oxacillin or nafcillin or vancomycin

If the organism is identified as methicillin-sensitive Staphylococcus aureus, clindamycin plus oxacillin or nafcillin is recommended.

Vancomycin may be used in place of oxacillin or nafcillin in patients who are allergic to penicillin.

Additional antibiotics may be needed for treating superinfections that may occur.

Treatment duration should be individualised, especially if there is a deep-seated infection. If bacteraemic, the patient should be treated for 14 days. Usually treatment is for 14 days after the last positive culture is obtained at surgery.

Primary options

clindamycin: 900 mg intravenously every 8 hours

-- AND --

oxacillin: 2 g intravenously every 4 hours

or

nafcillin: 2 g intravenously every 4 hours

or

vancomycin: 15-20 mg/kg intravenously every 12 hours

Plus – intensive care unit support

Back
ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-sensitive
Plus – 

intensive care unit support

Treatment recommended for ALL patients in selected patient group

General intensive care preventive measures include stress ulcer prophylaxis with H2 antagonists or proton-pump inhibitors, deep venous thrombosis prophylaxis with heparin or low-molecular weight heparin, compression stockings, and enteral nutrition.[83][91][92]​ The American Diabetes Association recommends a general glucose goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in most critically ill patients with diabetes, preferably by using an insulin infusion protocol; however, more stringent control of blood glucose, in the range of 110-140 mg/dL, may be appropriate in a selected population of critically ill patients (such as critically ill patients undergoing surgery), if that can be achieved without the risk of hypoglycaemia.[93]​ ​The Surviving Sepsis Campaign recommends the use of validated insulin infusion protocols targeting a blood glucose level of <10 mmol/L (<180 mg/dL).[83]​ 

Patients with evidence of acute respiratory distress syndrome should receive lung-protective ventilation using maximum plateau pressures <30 cm H₂O and permissive hypercapnia to limit pulmonary damage.[94]

Initial supportive therapy such as aggressive fluid resuscitation, vasopressor support for refractory hypotension, haemodynamics optimisation, and surgical debridement initiated before confirmation of the cause must be continued. Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension. The use of the vasopressor dopamine has been associated with higher mortality and more arrhythmic events compared with noradrenaline administration.[90]​ Intravenous corticosteroids should be administered for patients with ongoing vasopressor requirements or vasopressor-refractory septic shock.[83] Consult a specialist for guidance on suitable vasopressor regimens and doses.

Source control is mandatory, including drainage of any existing abscesses and removal of the tampon, if present.

Consider – topical mupirocin

Back
ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-sensitive
Consider – 

topical mupirocin

Additional treatment recommended for SOME patients in selected patient group

Treatment with mupirocin has been suggested to eradicate a positive nasal culture for Staphylococcus, but there are no data to support this practice.

Primary options

mupirocin topical: (2%) apply to nares twice daily for 5 days

confirmed staphylococcal toxic shock syndrome: methicillin-resistant

1st line – clindamycin + vancomycin or linezolid

Back
ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-resistant
1st line – 

clindamycin + vancomycin or linezolid

If MRSA is identified, combination therapy with clindamycin plus vancomycin or linezolid should be given.

Additional antibiotics may be needed for treating superinfections that may occur.

Treatment duration should be individualised, especially if there is a deep-seated infection. If bacteraemic, the patient should be treated for 14 days. Usually treatment is for 14 days after the last positive culture is obtained at surgery.

Primary options

clindamycin: 900 mg intravenously every 8 hours

-- AND --

vancomycin: 15-20 mg/kg intravenously every 12 hours

or

linezolid: 600 mg intravenously every 12 hours

Plus – intensive care unit support

Back
ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-resistant
Plus – 

intensive care unit support

Treatment recommended for ALL patients in selected patient group

General intensive care preventive measures include stress ulcer prophylaxis with H2 antagonists or proton-pump inhibitors, deep venous thrombosis prophylaxis with heparin or low-molecular weight heparin, compression stockings, and enteral nutrition.[83][91][92]​​​ The American Diabetes Association recommends a general glucose goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in most critically ill patients with diabetes, preferably by using an insulin infusion protocol; however, more stringent control of blood glucose, in the range of 110-140 mg/dL, may be appropriate in a selected population of critically ill patients (such as critically ill patients undergoing surgery), if that can be achieved without the risk of hypoglycaemia.[93]​ The Surviving Sepsis Campaign recommends the use of validated insulin infusion protocols targeting a blood glucose level of <10 mmol/L (<180 mg/dL).[83]​ 

Patients with evidence of acute respiratory distress syndrome should receive lung-protective ventilation using maximum plateau pressures <30 cm H₂O and permissive hypercapnia to limit pulmonary damage.[94] 

Initial supportive therapy such as aggressive fluid resuscitation, vasopressor support for refractory hypotension, haemodynamics optimisation, and surgical debridement initiated before confirmation of the cause must be continued. Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension. The use of the vasopressor dopamine has been associated with higher mortality and more arrhythmic events compared with noradrenaline administration.[90]​ Intravenous corticosteroids should be administered for patients with ongoing vasopressor requirements or vasopressor-refractory septic shock.[83]​ Consult a specialist for guidance on suitable vasopressor regimens and doses.

Source control is mandatory, including drainage of any existing abscesses and removal of the tampon, if present.

Consider – topical mupirocin

Back
ACUTE
|
confirmed staphylococcal toxic shock syndrome: methicillin-resistant
Consider – 

topical mupirocin

Additional treatment recommended for SOME patients in selected patient group

Treatment with mupirocin has been suggested to eradicate a positive nasal culture for Staphylococcus, but there are no data to support this practice.

Primary options

mupirocin topical: (2%) apply to nares twice daily for 5 days

clinical toxic shock syndrome without confirmed cultures

1st line – continued empirical antibiotic therapy

Back
ACUTE
|
clinical toxic shock syndrome without confirmed cultures
1st line – 

continued empirical antibiotic therapy

Patients with clinical toxic shock syndrome without confirmed cultures should receive continued empirical therapy.

Additional antibiotics may be needed for treating superinfections that may occur.

Treatment duration should be individualised, especially if there is a deep-seated infection. If bacteraemic, the patient should be treated for 14 days. Usually treatment is for 14 days after the last positive culture is obtained at surgery.

Primary options

clindamycin: 900 mg intravenously every 8 hours

-- AND --

imipenem/cilastatin: 500 mg intravenously every 6 hours

More

or

meropenem: 1 g intravenously every 8 hours

or

ticarcillin/clavulanic acid: 3.1 g intravenously every 4 hours

More

or

piperacillin/tazobactam: 4.5 g intravenously every 6 hours

More

or

vancomycin: 15-20 mg/kg intravenously every 12 hours

Plus – intensive care unit support

Back
ACUTE
|
clinical toxic shock syndrome without confirmed cultures
Plus – 

intensive care unit support

Treatment recommended for ALL patients in selected patient group

General intensive care preventive measures include stress ulcer prophylaxis with H2 antagonists or proton-pump inhibitors, deep venous thrombosis prophylaxis with heparin or low-molecular weight heparin, compression stockings, and enteral nutrition.[83][91][92]​​​ The American Diabetes Association recommends a general glucose goal of 7.8 to 10.0 mmol/L (140-180 mg/dL) in most critically ill patients with diabetes, preferably by using an insulin infusion protocol; however, more stringent control of blood glucose, in the range of 110-140 mg/dL, may be appropriate in a selected population of critically ill patients (such as critically ill patients undergoing surgery), if that can be achieved without the risk of hypoglycaemia.[93]​​ The Surviving Sepsis Campaign recommends the use of validated insulin infusion protocols targeting a blood glucose level of <10 mmol/L (<180 mg/dL).[83]​​

Patients with evidence of acute respiratory distress syndrome should receive lung-protective ventilation using maximum plateau pressures <30 cm H₂O and permissive hypercapnia to limit pulmonary damage.[94]

Initial supportive therapy such as aggressive fluid resuscitation, vasopressor support for refractory hypotension, haemodynamics optimisation, and surgical debridement initiated before confirmation of the cause must be continued. Massive fluid resuscitation is often needed because of the diffuse capillary leak phenomenon and the refractory hypotension. The use of the vasopressor dopamine has been associated with higher mortality and more arrhythmic events compared with noradrenaline administration.[90] Intravenous corticosteroids should be administered for patients with ongoing vasopressor requirements or vasopressor-refractory septic shock.[83]​ Consult a specialist for guidance on suitable vasopressor regimens and doses.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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