Treatment
Severe forms require more aggressive treatment with IV antistaphylococcal antibiotics and
extra care of denuded skin to prevent secondary infection, fluid losses, and to maintain body
temperature, especially in neonates. In methicillin-sensitive strains (methicillin-susceptible
S. aureus, MSSA), a penicillinase-resistant penicillin nafcillin or oxacillin (2 g IV every 4–6 hours)
is the drug of choice. Cefazolin (1–2 g IV every 8 hours) is an alternative treatment that can also be
used in patients with histories of delayed-type penicillin allergy. In methicillin-resistant strains
(MRSA) vancomycin (1 g or 15 mg/kg IV every 12 hours), trimethoprim/sulfamethoxazole
(320/1600 IV every 12 hours), linezolid (600 mg IV or orally every 12 hours), and other agents like
daptomycin (4 mg/kg/day IV) for skin and soft tissue infections (6 mg/kg/day IV for severe
infections), tigecycline (100 mg IV initial dose followed by 50 mg IV every 12 hours),
quinupristin-dalfopristin (7.5 mg/kg IV every 8 hours), and telavancin (10 mg/kg IV every
24 hours) are treatment options (94,95). Telavancin, linezolid, daptomycin, tigecycline, and
quinupristin-dalfopristin can be used for vancomycin-intermediateS. aureus(VISA). For VRSA
strains testing should be performed (96,97). Oritavancin, dalbavancin, ceftobiprole, and
ceftaroline are newer agents under development for treatment of resistant strains (97).
Toxic Shock Syndrome
TSS is a rapid-onset illness causing fever, hypotension, rash, multiple organ system
dysfunctions, and desquamation. Infection withS. aureusproduces classical TSS, whereas
S. pyogenescauses a modified form of TSS known as either streptococcal TSS or toxic shock–like
syndrome (TSLS). TSLS displays many of the typical TSS symptoms with the addition of severe
soft tissue necrosis (98). Diagnosis of TSLS caused by streptococci is based on a constellation of
clinical and laboratory signs as proposed by the Centers for Disease Control and Prevention
(Table 4) (99,100). There are two clinical forms of TSS: menstrual TSS and nonmenstrual TSS.
Menstrual TSS starts within three days of the beginning or end of menses and is primarily
associated with the use of high absorbency tampons. Clinical signs include high fever,
capillary leak syndrome with hypotension and hypoalbunemia, generalized nonpitting edema,
and a morbilliform rash, followed by desquamation after a few days. TSST-1 and
Table 4 Streptococcal Toxic Shock Syndrome: Clinical Case Definition (CDC)
An illness with the following clinical manifestations occurring within the first 48 hr of hospitalization or, for a
nosocomial case, within the first 48 hr of illness:
Hypotension defined by a systolic blood pressure90 mmHg for adults or less than the fifth percentile by age
for children aged<16 yr. Multiorgan involvement characterized by two or more of the following:
Renal impairment: Creatinine2 mg/dL ( 177 mmol/L) for adults or greater than or equal to twice the upper
limit normal for age. In patients with preexisting renal disease, a greater than twofold elevation over the
baseline level.
Coagulopathy: Platelets100,000/mm^3 ( 100 106 /L) or disseminated intravascular coagulation, defined
by prolonged clotting times, low fibrinogen level, and the presence of fibrin degradation products
Liver involvement: Alanine aminotransferase, aspartate aminotransferase, or total bilirubin levels greater than
or equal to twice the upper limit of normal for the patient’s age. In patients with preexisting liver disease, a
greater than twofold increase over the baseline level.
Acute respiratory distress syndrome: Defined by acute onset of diffuse pulmonary infiltrates and hypoxemia
in the absence of cardiac failure or by evidence of diffuse capillary leak manifested by acute onset of
generalized edema, or pleural or peritoneal effusions with hypoalbuminemia
A generalized erythematous macular rash that may desquamate. Soft tissue necrosis, including necrotizing
fasciitis or myositis, or gangrene
Laboratory criteria for diagnosis
.Isolation of group AStreptococcus
Case classification
Probable: A case that meets the clinical case definition in the absence of another identified etiology for the illness
and with isolation of group AStreptococcusfrom a nonsterile site
Confirmed: A case that meets the clinical case definition and with isolation of group AStreptococcusfrom a
normally sterile site (e.g., blood or cerebrospinal fluid or, less commonly, joint, pleural, or pericardial fluid)
Source: Adapted from Ref. 99.
312 Sharma and Saravolatz