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We welcome the Education and Debate article on Toxic Shock
Syndrome(1), which helps improve the profile of this potentially
devastating disease and enhances diagnostic recognition.
It is however important to highlight some specific areas in
prevention, diagnosis and therapy which are not fully discussed within
As the authors state, early diagnosis can be difficult but...
As the authors state, early diagnosis can be difficult but is crucial
to improving prompt intervention and therapy. Case definitions are
complex but are well established and importantly differentiate
staphylococcal from streptococcal toxic shock (2). It is important to
realise that streptococcal toxic shock does not always present with a
rash, nor is pyrexia included within the case definition, although
isolation of GAS is required. Rash is therefore not an essential
diagnostic criteria when assessing children initially before the results
of cultures are known.
Prevention is important and there was little expansion on the role of
prophylactic antibiotics in burns which has gathering evidence for
efficacy in the prevention of toxic shock syndrome(8,9).
The authors state that effective antitoxin therapy is considered an
essential part of management, but describe only the potential for
antitoxin blocking antibody. There is however a growing literature on the
specific antitoxin effect of antibiotics such as clindamycin,
aminoglycosides and linezolid which have been shown to reduce TSST 1 and
streptococcal exotoxin A (3,4,5). Clindamycin is now an accepted and
recommended adjunctive therapy for both staphylococcal and streptococcal
toxic shock (2-5).
Inhibition of T cell activation by blocking or inactivating
staphylococcal and streptococcal superantigens is theoretically attractive
(6). Its use in streptococcal toxic shock has suggested benefit,
(statistically significant results perhaps prevented by early termination
of this study because of slow recruitment) (7), but there have been no
such studies with FFP, which the authors suggest is useful. Although
specific anti-toxin antibody may be detected in FFP, the level of this
antibody is likely to be significantly lower than in IVIG and hence
passive immunity may not be achieved. There is no other evidence base for
FFP apart from the authors’ experience, and although it may well have been
successful for the authors is not consistent with other accepted
Management guidelines for Toxic shock are specifically outlined by
the American Academy of Pediatrics (2) as follows:
• Fluid management to maintain adequate venous return and cardiac filling
pressures to prevent end organ damage.
• Anticipatory management of multi system organ failure.
• Parental antimicrobial therapy at maximal doses for age.
o Kill organism with bactericidal cell wall inhibitor (e.g. beta-lactamase
resistant antistaphylococcal antimicrobials).
o Stop enzyme, toxin, or cytokine production with protein synthesis
inhibitor (e.g. clindamycin).
• Intravenous immune globulin may be considered for an infection
refractory to several hours of aggressive therapy, in the presence of an
undrainable focus, or where there is persistent oliguria with pulmonary
The guidelines for the management of toxic shock syndrome should
include Clindamycin as an adjunctive treatment and IVIG where necessary.
FFP should not be used as a specific anti-toxin (without an evidence base)
but may be useful as part of volume expansion management.
1. A Young, K Thornton. Toxic shock syndrome in burns: diagnosis and
management. Arch Dis Child Educ Pract Ed 2007;92:ep97-ep100.
2. American Academy of Pediatrics [Toxic Shock Syndrome]. In: Pickering
LK,ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th
edition. Elk Grove Village, IL: American Academy of Pediatrics;2000:p580.
3. Chuang et al. Toxic shock syndrome in children epidemiologic,
pathogenis, and management. Pediatric drugs. 2005;7(1):11-25.
4. Coyle E.A, Cha R, Rybak M J. Influences of linezolid, penicillin and
clindamycin alone and in combination on streptococcal pyrogenic ExotoxinA
release. Antimicrobial Agents and Chemotherapy. 2003;47(5);1752-1755.
5. Annane D, Clair B, Salomon J. Managing toxic shock syndrome with
antibiotics. Expert Opin. Pharmacother. 2004;5(8):1701-1709.
6. Darenberg J et al. Differences in potency of Intravenous polyspecific
immunoglobulin G against streptococcal and staphylococcal superantigens:
implications for therapy of toxic shock syndrome. CID. 2004:38:836-842.
7. Darenberg J et al. Intravenous immunoglobulin G therapy and
streptococcal toxic shock syndrome. CID. 2003;37:333-40.
8. Abid Rashid, Alastair P. Brown, Khalid Khan. On the use of
prophylactic antibiotics in prevention of toxic shock syndrome. Burns 31
9. Edwards-Jones V, Dawson MM, Childs C. A survey into toxic shock
syndrome (TSS) in UK burns units. Burns 26 (2000) :323–33.