Primary prevention

Streptococcal toxic shock syndrome

The spread of all types of group A streptococcal infections can be reduced by good hand washing, especially after coughing and sneezing and before preparing foods or eating.[77]​

Patients with confirmed strep throat should follow national recommendations to prevent onward transmission. The Centers for Disease Control and Prevention (CDC) in the US recommends that patients stay at home (from work, school, or daycare) until they are afebrile and at least 12-24 hours after commencing antibiotic treatment.[76] UK guidance recommends that patients with strep throat isolate for at least 24 hours after the start of treatment with an appropriate antibiotic.[77]​​

All wounds should be kept clean and observed for possible signs of infection such as redness, swelling, drainage, and pain at the wound site.

National guidelines should be followed for recommendations on chemoprophylaxis. In general, it is not necessary for all people exposed to someone with invasive group A streptococcal toxic shock syndrome (TSS) to receive antibiotic therapy to prevent infection.[78]​ However, clinicians should alert all close contacts to signs and symptoms of TSS and advise them to seek medical attention if they develop a fever within 30 days of the index patient.

In certain circumstances, antibiotic therapy may be appropriate for a close contact of a confirmed case of invasive group A streptococcal infection, including TSS. A close contact can be defined as:

  • Someone who has had prolonged contact with the case in a household-type setting during the 7 days before diagnosis of infection and up to 24 hours after initiation of appropriate antimicrobial therapy in the index case. Examples of such contacts would be those with an overnight stay in the same household (including extended household if the case has stayed at another household), pupils in the same dormitory, intimate partners, or university students sharing a kitchen in a hall of residence[77]

  • Those who have had direct contact with mucous membranes or oral or nasal secretions[79]

  • Injection drug users who have shared a needle[79] 

  • Contacts in child care settings, select hospital contacts, and select long-term care facility contacts.[79]

The Centers for Disease Control and Prevention only recommends considering antibiotic prophylaxis for close contacts of patients with streptococcal TSS aged ≥65 years.[78]

Guidelines from the Canadian Paediatric Society recommend that:[79]

  • Chemoprophylaxis should only be offered to close contacts of a confirmed case of severe invasive group A streptococcal disease who have been exposed during the period from 7 days before the onset of symptoms in the index case to 24 hours after the index case has initiated antimicrobial therapy.

  • Chemoprophylaxis should be started as soon as possible, and preferably within 24 hours of identifying the case. Chemoprophylaxis is still recommended up to 7 days after the last contact with the index case.

UK guidance recommends that:[77]

  • Chemoprophylaxis should be offered to high-risk close contacts. High-risk close contacts include those ages ≥75 years or ≤28 days; women during late pregnancy (≥37 weeks) or ≤28 days postpartum; and those with open chickenpox lesions within 7 days prior to diagnosis of the index case or within 48 hours after the index case has commenced antibiotics, if exposure is ongoing.

  • Chemoprophylaxis may be considered for other contacts if multiple cases of confirmed or probable invasive group A streptococcus infection are identified within the same school/other childcare setting, or care home. If there are multiple cases within one household, chemoprophylaxis should be offered to the entire household.

Staphylococcal TSS

Education regarding extended tampon use and the withdrawal of highly absorbent tampons from the market has decreased the incidence of staphylococcal TSS.[69]​ Lack of seroconversion after an acute staphylococcal illness may be used as a marker for patients at risk for recurrent disease.[15]​ These patients should be treated for a protracted course with antistaphylococcal antibodies for at least 2 weeks.

Secondary prevention

The risk of secondary cases of invasive disease is low at 2.9 per 1000.[95] Several regimens have been successful in eradicating group A streptococcus from the pharynx of chronic carriers (i.e., rifampin plus intramuscular benzathine penicillin or a 10-day course of a second-generation cephalosporin or clindamycin).[125] However, there are limited data concerning chemoprophylaxis for severe invasive group A streptococcal or staphylococcal infections.

Women who have had toxic shock syndrome (TSS) should avoid the use of tampons while menstruating. If use is unavoidable, tampons should be changed every 4-8 hours.[129]

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