Toxic shock syndrome in Gram-positive cocci infections

Abstract

Although Gram-positive cocci are implicated in half of the documented causes of sepsis, toxic shock syndrome (TSS) due to these organisms is rare. By definition, TSS, whether related to staphylococcus (staph-TSS) or streptococcus (strep-TSS), is characterized by the production of superantigen exotoxins, alone or in association with other virulence factors, inducing an excessive production of pro-inflammatory cytokines. Staph-TSS may be menstrual (colonisation of an absorbent tampon or intrauterine device [IUD]: production of TSS toxin-1 (TSST-1), negative blood culture, low mortality) or non-menstrual (usually postsurgical colonisation or local infection: production of TSST-1 or enterotoxin, positive blood culture in 50% of the cases, 20-25% mortality rate). Strep-TSS is usually associated with necrosing fasciitis (60% positive blood culture, mortality up to 80% in the case with associated myositis). Organ failure is managed like septic shock. Mechanical eradication of the toxin source is mandatory (removal of tampon or IUD in menstrual staph-TSS, surgical revision even without signs of local inflammation in post-surgical non-menstrual staph-TSS, and aggressive surgery in strep-TSS with necrosing fasciitis). Antibiotic treatment should be bactericidal (high-dose β-lactam). In addition, it is recommended to add an antimicrobial with antitoxinic activity such as clindamycin (a large majority of Staphylococcus aureus and Streptococcus pyogenes strains implicated in TSS in France are susceptible to clindamycin) or polyvalent immunoglobulins, especially in case of shock with refractory hypotension.