id.toxic-shock-syndrome.v1PRODUCTION

id.toxic-shock-syndrome.v1

Toxic Shock Syndrome (Staphylococcal & Streptococcal)

infectious_diseaseacuteadultpediatric

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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Superantigen-mediated distributive / toxic shock + MODS: staphylococcal TSS (TSST-1 menstrual — tampon/barrier-contraceptive; or enterotoxin non-menstrual — surgical wound/nasal-or-vaginal packing/postpartum/burn/sinusitis/abscess/influenza; usually non-bacteraemic; diffuse macular erythroderma → late palmar/plantar desquamation) vs streptococcal TSS (group A streptococcus; ≈ 60% bacteraemic; ≈ 50% with necrotising soft-tissue focus — far higher mortality) × early (fever/erythroderma/myalgia/GI prodrome — pre-hypotension) vs shock/MODS vs late (desquamation — confirmatory) × source identified (tampon/packing/wound/abscess/nec fasc) vs occult (CDC TSS case definitions; Stevens IDSA SSTI 2014 PMID 24973422)

Inputs

Actions

Advance rule

Set

Advance when

TSS phenotype framed (organism × menstrual status × stage × source)

Patient inputs (17)

temperature*vital • CONTEXT

Fever ≥ 38.9 °C is a CDC TSS case-definition criterion (staphylococcal) and a sepsis-screen component; absence of fever is atypical and prompts reconsideration

hr*vital • CONTEXT

Tachycardia supports distributive/toxic shock and drives fluid-responsiveness assessment in the resuscitation bundle (SSC 2026)

tampon_packing_or_foreign_body*history • CONTEXT

not present

Tampon / barrier contraceptive (menstrual staph TSS) or vaginal/nasal packing / foreign body (packing-associated) — immediate removal is mandatory primary source control (CDC; Stevens IDSA SSTI 2014)

menstrual_vs_nonmenstrual_context*history • CONTEXT

not present

Menstrual (tampon/barrier contraceptive) vs non-menstrual (surgical wound, packing, postpartum, burn, sinusitis, abscess, influenza-associated) staphylococcal context — sets the source-control target and informs prognosis (non-menstrual higher mortality) (CDC)

diffuse_macular_erythroderma*symptom • ENTRY

Diffuse macular "sunburn" erythroderma (± mucous-membrane hyperaemia; later palmar/plantar desquamation) is the pivotal CDC staphylococcal TSS sign and a generalised erythematous rash is a CDC streptococcal organ-system criterion (CDC TSS case definitions)

blood_culture*lab • INITIAL_WORKUP

Blood cultures (before antibiotics if no delay): usually negative in staphylococcal TSS (toxin-mediated) — a negative result does NOT exclude it; positive sterile-site GAS = CDC-confirmed streptococcal TSS (CDC; SSC 2026)

source_site_culture*lab • INITIAL_WORKUP

Cultures from the source site (vagina, nares, wound, abscess, soft tissue) — identify S. aureus vs group A streptococcus to drive organism-directed de-escalation (Stevens IDSA SSTI 2014)

lactate*lab • INITIAL_WORKUP

Hour-1 bundle marker + lactate-clearance trend in TSS distributive/toxic shock (SSC 2026)

cbc_with_platelets*lab • INITIAL_WORKUP

Platelets < 100,000 /µL is a CDC haematologic organ-system criterion; baseline + trend; leukocytosis with left shift supports the syndrome (CDC TSS case definitions)

creatinine_and_renal_function*lab • INITIAL_WORKUP

Renal impairment is a CDC organ-system criterion; baseline + serial for vancomycin AUC-targeted dosing + antibiotic renal dose adjustment (CDC; Rybak ASHP/IDSA 2020 PMID 32191793)

lft_and_coag*lab • INITIAL_WORKUP

Hepatic involvement + coagulopathy are CDC organ-system criteria; LFT + coagulation panel define organ-failure burden and DIC risk (CDC TSS case definitions)

sbp*vital • RED_FLAGS

Hypotension (SBP < 90 mmHg adult, or orthostatic drop, or age-adjusted in children) is a CDC TSS case-definition criterion and the trigger for the SSC Hour-1 bundle + cross-route id.sepsis.core.v1 (CDC; SSC 2026)

soft_tissue_pain_out_of_proportion*symptom • RED_FLAGS

Severe pain out of proportion / rapidly extending soft-tissue infection is the early clue of streptococcal TSS with necrotising fasciitis / myositis → emergent surgical exploration (Stevens IDSA SSTI 2014; Sartelli WSES/SIS 2021 PMID 34022909)

map*vital • TREATMENT

Direct vasopressor titration target in TSS distributive/toxic shock — MAP ≥ 65 mmHg (SSC 2026)

creatine_kinaselab • BRANCHING_WORKUP

CK ≥ 2× ULN is a CDC muscular organ-system criterion and supports streptococcal myositis underlying STSS (CDC; Stevens IDSA SSTI 2014)

soft_tissue_or_surgical_focushistory • CONTEXT

not present

Surgical wound / abscess / skin-soft-tissue focus — drain/explore even if locally bland (toxin out of proportion); a necrotising focus mandates emergent debridement (Stevens IDSA SSTI 2014)

alternative_serologieslab • DIFFERENTIAL

Negative serologies for RMSF, leptospirosis, measles are required for the CDC staphylococcal TSS confirmed case definition (excludes erythroderma mimics) (CDC)

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Severity triggers (8)

8 need judgement

informationallife_threateningtss_shock_or_mods
Toxic shock syndrome with hypotension (SBP < 90 mmHg / orthostatic drop / age-adjusted in children) + multi-organ involvement (≥ 3 organ systems staphylococcal / ≥ 2 streptococcal per CDC) — distributive/toxic shock; SSC Hour-1 bundle + cross-route id.sepsis.core.v1 with carryover (CDC TSS case definitions; SSC 2026)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningstreptococcal_tss_with_nec_fasc
Streptococcal toxic shock syndrome with a necrotising soft-tissue infection (necrotising fasciitis / myositis — ≈ 50% of STSS) — EMERGENT surgical debridement is the dominant survival determinant; penicillin G + clindamycin + IVIG; cross-route id.necrotising-fasciitis.core.v1 (do NOT delay surgery for imaging) (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningrapidly_progressive_soft_tissue_pain
Rapidly progressive soft-tissue pain out of proportion ± hemorrhagic bullae / crepitus / anaesthesia + systemic toxicity — early clue of streptococcal TSS with necrotising fasciitis / myositis; EMERGENT surgical exploration (do NOT delay for imaging) + cross-route id.necrotising-fasciitis.core.v1 (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningrefractory_shock_consider_ivig
Refractory toxic shock despite source control + antibiotics, OR confirmed streptococcal TSS with multi-organ failure — adjunctive IVIG (1 g/kg IV day 1 → 0.5 g/kg IV days 2-3) for superantigen neutralisation; reassess for retained focus / undrained collection / missed nec fasc (Stevens IDSA SSTI 2014 Class IIa; Darenberg CID 2003 PMID 12884159; Linnér CID 2014 PMID 24928291)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretampon_or_packing_in_situ
Tampon / vaginal or nasal packing / foreign body in situ in a person with fever + diffuse erythroderma ± hypotension — menstrual or packing-associated staphylococcal TSS; IMMEDIATE removal is the mandatory primary source-control act (CDC; Stevens IDSA SSTI 2014 PMID 24973422)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveremrsa_risk_empiric_vancomycin
TSS with MRSA risk (prior MRSA, healthcare exposure, IVDU, high local prevalence, severe sepsis) OR organism not yet identified — empiric vancomycin (AUC-targeted) until MSSA / S. aureus excluded; narrow to an anti-staph β-lactam once MSSA confirmed (β-lactam superior to vancomycin for MSSA) (Stevens IDSA SSTI 2014; Rybak ASHP/IDSA 2020 PMID 32191793)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereoccult_source_hunt
Toxin syndrome (fever + diffuse erythroderma + organ involvement ± hypotension) WITHOUT an obvious focus — characteristic of staphylococcal TSS; aggressively examine vagina/nares/wounds/sinuses/pharynx + image for a deep collection + occult-focus hunt; do NOT anchor on absent local signs (CDC; Stevens IDSA SSTI 2014 PMID 24973422)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateearly_tss_pre_hypotension
Early TSS — fever + diffuse macular erythroderma + severe myalgia + vomiting/diarrhoea + headache BEFORE frank hypotension; high index of suspicion → cultures + remove any tampon/packing + start empiric anti-toxin regimen + serial reassessment for rapid decompensation (CDC TSS case definitions; Stevens IDSA SSTI 2014 PMID 24973422)
Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

TSS source control (remove tampon/packing/foreign body; emergent debridement if strep + nec fasc) + anti-toxin antibiotics (anti-staph β-lactam/vancomycin OR penicillin G for GAS, ALWAYS + clindamycin toxin suppression) + adjunctive IVIG (strep / refractory) + hemodynamic resuscitation (SSC 2026 Hour-1 bundle)

axis: tss_source_control_anti_toxin_ivig_resuscitationstep source_control_remove_foreign_body_and_debride - Source control — remove tampon/packing/foreign body; explore + drain surgical-wound/abscess focus; EMERGENT surgical debridement if streptococcal TSS + necrotising soft-tissue infection

Selected step "Source control — remove tampon/packing/foreign body; explore + drain surgical-wound/abscess focus; EMERGENT surgical debridement if streptococcal TSS + necrotising soft-tissue infection" — ANY TSS — tampon/packing/foreign body in situ, surgical-wound/abscess focus, or necrotising soft-tissue infection (streptococcal TSS / nec fasc / myositis)

remove_foreign_body_and_surgical_source_control
first line
source_control_procedure
Immediate removal of tampon / vaginal or nasal packing / foreign body; explore + drain surgical-wound or abscess focus even if locally bland (toxin out of proportion); EMERGENT surgical debridement + mandatory 24-48 h second-look for streptococcal TSS with necrotising fasciitis/myositis (cross-route id.necrotising-fasciitis.core.v1) — do NOT delay surgery for imaging • procedural • immediate / emergent (within 1 h of recognition for nec fasc)
triggers: tampon_or_packing_in_situ, surgical_wound_or_abscess_focus, streptococcal_tss_with_nec_fasc, necrotising_soft_tissue_infection
Source control is non-negotiable + time-critical — foreign-body removal is the primary source-control act in menstrual/packing staph TSS; emergent debridement is the dominant survival determinant in streptococcal TSS with necrotising soft-tissue infection (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909; CDC)

outpatient playbook — drug actions (2)

1. oral antibiotic completion (if a finite organism-directed course continues)
Per organism + susceptibility for the remainder of the course • PO • per agent
trigger: Source controlled + organ failure recovered + finite course continues
Complete the organism-directed course; duration individualised to source control + organ-failure resolution (Stevens IDSA SSTI 2014)
2. S. aureus carriage decolonisation (recurrent menstrual staph TSS — consider)
Topical intranasal mupirocin ± chlorhexidine body wash per local decolonisation protocol • topical • per protocol
trigger: Recurrent menstrual staphylococcal TSS / persistent S. aureus carriage
Reduce recurrence risk in menstrual staphylococcal TSS — adjunct to tampon avoidance (CDC; Stevens IDSA SSTI 2014)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever (≥ 38.9 °C) + diffuse macular "sunburn" erythroderma ± mucous-membrane hyperaemia — toxic shock syndrome until proven otherwise; obtain cultures + remove any tampon/packing + start empiric anti-toxin regimen (CDC staph TSS case definition; Stevens IDSA SSTI 2014 PMID 24973422); Hypotension (SBP < 90 mmHg or orthostatic drop) with fever + diffuse erythroderma ± ≥ 3-organ involvement — TSS shock; SSC Hour-1 bundle + cross-route id.sepsis.core.v1 (CDC; SSC 2026); Tampon / vaginal or nasal packing / foreign body in situ with fever ± rash ± hypotension — menstrual or packing-associated staphylococcal TSS; REMOVE the foreign body immediately (primary source control) (CDC; Stevens IDSA SSTI 2014).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Toxic Shock Syndrome (Staphylococcal & Streptococcal)** (id.toxic-shock-syndrome.v1).
Phenotype framing: TSS vs septic shock without toxin (erythroderma + mucous-membrane hyperaemia + late desquamation + toxin out of proportion pivot) vs drug reaction / DRESS (drug latency + eosinophilia + facial oedema pivot) vs scarlet fever (sandpaper rash + pharyngitis without shock pivot) vs staphylococcal scalded-skin syndrome (Nikolsky-positive intraepidermal cleavage pivot) vs leptospirosis / RMSF / measles (serologies + exposure + Koplik/petechiae pivot — CDC requires negative alternative serologies for confirmed staph TSS) vs Kawasaki disease / KD-shock syndrome (young child + coronary risk + conjunctivitis/mucositis — recognised overlap, co-manage); staphylococcal vs streptococcal TSS (GAS sterile-site isolation + necrotising soft-tissue focus + bacteraemia pivot — strep mortality far higher → IVIG + emergent-surgery emphasis) (CDC TSS case definitions; Stevens IDSA SSTI 2014)
Scope: Superantigen-mediated distributive / toxic shock + MODS: staphylococcal TSS (TSST-1 menstrual — tampon/barrier-contraceptive; or enterotoxin non-menstrual — surgical wound/nasal-or-vaginal packing/postpartum/burn/sinusitis/abscess/influenza; usually non-bacteraemic; diffuse macular erythroderma → late palmar/plantar desquamation) vs streptococcal TSS (group A streptococcus; ≈ 60% bacteraemic; ≈ 50% with necrotising soft-tissue focus — far higher mortality) × early (fever/erythroderma/myalgia/GI prodrome — pre-hypotension) vs shock/MODS vs late (desquamation — confirmatory) × source identified (tampon/packing/wound/abscess/nec fasc) vs occult (CDC TSS case definitions; Stevens IDSA SSTI 2014 PMID 24973422)

No severity triggers fired against current inputs.

Plan

Regimen axis: **TSS source control (remove tampon/packing/foreign body; emergent debridement if strep + nec fasc) + anti-toxin antibiotics (anti-staph β-lactam/vancomycin OR penicillin G for GAS, ALWAYS + clindamycin toxin suppression) + adjunctive IVIG (strep / refractory) + hemodynamic resuscitation (SSC 2026 Hour-1 bundle)** — step "Source control — remove tampon/packing/foreign body; explore + drain surgical-wound/abscess focus; EMERGENT surgical debridement if streptococcal TSS + necrotising soft-tissue infection".
1. remove_foreign_body_and_surgical_source_control Immediate removal of tampon / vaginal or nasal packing / foreign body; explore + drain surgical-wound or abscess focus even if locally bland (toxin out of proportion); EMERGENT surgical debridement + mandatory 24-48 h second-look for streptococcal TSS with necrotising fasciitis/myositis (cross-route id.necrotising-fasciitis.core.v1) — do NOT delay surgery for imaging procedural immediate / emergent (within 1 h of recognition for nec fasc) (source_control_procedure, first line) — Source control is non-negotiable + time-critical — foreign-body removal is the primary source-control act in menstrual/packing staph TSS; emergent debridement is the dominant survival determinant in streptococcal TSS with necrotising soft-tissue infection (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909; CDC)

Setting playbook (outpatient) — Recovery + desquamation course, recurrence counselling (avoid high-absorbency tampons in menstrual staph TSS — recurrence risk; nasal/vaginal S. aureus carriage decolonisation consideration), GAS-contact chemoprophylaxis discussion for severe invasive STSS, organ-recovery follow-up, return precautions (Stevens IDSA SSTI 2014; CDC)
2. oral antibiotic completion (if a finite organism-directed course continues) Per organism + susceptibility for the remainder of the course PO per agent — Source controlled + organ failure recovered + finite course continues (Complete the organism-directed course; duration individualised to source control + organ-failure resolution (Stevens IDSA SSTI 2014))
3. S. aureus carriage decolonisation (recurrent menstrual staph TSS — consider) Topical intranasal mupirocin ± chlorhexidine body wash per local decolonisation protocol topical per protocol — Recurrent menstrual staphylococcal TSS / persistent S. aureus carriage (Reduce recurrence risk in menstrual staphylococcal TSS — adjunct to tampon avoidance (CDC; Stevens IDSA SSTI 2014))

Non-pharmacologic actions:
- Patient education — recurrence precautions: avoid high-absorbency tampons / barrier contraceptives in menstrual staphylococcal TSS; recurrent fever/rash/hypotension → return immediately
- Organ-recovery follow-up (nephrology / hepatology / cardiology as involved)
- Residual-source / reconstructive follow-up (wound / nec-fasc grafting via id.necrotising-fasciitis.core.v1)
- GAS-contact public-health notification + chemoprophylaxis discussion for severe invasive streptococcal TSS

AVOID / contraindication checks:
- Remove tampon or packing or foreign body immediately primary source control (CDC; Stevens IDSA SSTI 2014 PMID 24973422)
- Emergent surgical debridement for streptococcal tss with necrotising soft tissue infection do not delay for imaging (Stevens IDSA SSTI 2014; Sartelli WSES/SIS 2021 PMID 34022909)
- Add clindamycin or linezolid protein synthesis inhibitor for toxin suppression regardless of organism (Stevens IDSA SSTI 2014; Stevens JID 1988 PMID 2839555)
- Clindamycin resistance in s pyogenes rising regionally confirm susceptibility (Stevens IDSA SSTI 2014)
- Clindamycin c diff counsel (Stevens IDSA SSTI 2014; DailyMed clindamycin)
- Penicillin g first line for confirmed group A streptococcus plus clindamycin (Stevens IDSA SSTI 2014)
- Vancomycin AUC target not trough (Rybak ASHP/IDSA 2020 vancomycin consensus — AUC/MIC 400 600; PMID 32191793)
- Vancomycin nephrotoxicity monitor renal and levels (FDA label)
- Ivig iga deficiency anaphylaxis and thrombosis warning (DailyMed IVIG)
- Linezolid serotonin syndrome and myelosuppression beyond 14d and lactic acidosis (FDA label)
- Broad spectrum antibiotics within 1h in toxic shock (Kumar CCM 2006 PMID 16625125; SSC 2026)
- Negative blood cultures do not exclude staphylococcal tss toxin mediated (CDC)

Monitoring

Regimen monitoring:
- Continuous MAP + lactate q2-4h until cleared (SSC 2026)
- Organ-failure trajectory — daily SOFA (renal/hepatic/coagulation/CNS/respiratory); platelets, creatinine, LFT, coagulation (CDC organ-system criteria)
- Source-control adequacy — failure to improve → retained tampon/packing, undrained collection, or missed nec fasc → re-examine + re-image + surgical re-look
- Culture-directed de-escalation — penicillin G + clindamycin for confirmed GAS; anti-staph β-lactam + clindamycin for MSSA
- Vancomycin AUC + serial creatinine (nephrotoxicity; Rybak ASHP/IDSA 2020 PMID 32191793)
- Clindamycin — C. diff surveillance + susceptibility confirmation (S. pyogenes resistance rising)
- Linezolid (protein-synthesis-inhibitor alternative) — CBC weekly if > 14 d (myelosuppression) + serotonin-syndrome screen
- IVIG — infusion-reaction / IgA-deficiency anaphylaxis / thrombosis surveillance (3-dose course over 72 h)
- Desquamation surveillance — palmar/plantar desquamation at 1-3 wk is expected + confirmatory (not a deterioration sign)

Setting (outpatient) monitoring:
- Clinical + organ-recovery trajectory to resolution
- Desquamation course (expected, self-limited)
- Recurrence surveillance (menstrual staphylococcal TSS recurs)
- Residual-source / reconstruction status if applicable

Follow-up plan: Recovery + palmar/plantar desquamation course (1-3 wk — confirmatory, expected); recurrence counselling — menstrual staphylococcal TSS recurs (avoid high-absorbency tampons; consider S. aureus nasal/vaginal carriage decolonisation); GAS-contact chemoprophylaxis discussion for severe invasive streptococcal TSS per public-health guidance; organ-recovery follow-up (renal/hepatic/cardiac as involved); return precautions (recurrent fever, rash, hypotension); address residual source (wound/abscess/nec-fasc reconstruction via id.necrotising-fasciitis.core.v1) (CDC; Stevens IDSA SSTI 2014)
- Close-out criterion: Recovery + recurrence-counselling + organ-recovery + return-precaution plan delivered; residual source addressed

Monitoring phase: Continuous MAP + lactate q2-4h until cleared (SSC 2026); organ-failure trajectory (renal/hepatic/coagulation/CNS/respiratory — daily SOFA); source-control adequacy (failure to improve → retained tampon/packing, undrained collection, or missed nec fasc → re-examine + re-image + surgical re-look); culture-directed de-escalation (penicillin G + clindamycin for confirmed GAS; anti-staph β-lactam + clindamycin for MSSA); vancomycin AUC + serial creatinine (nephrotoxicity; Rybak ASHP/IDSA 2020 PMID 32191793); clindamycin C. diff surveillance + susceptibility confirmation (S. pyogenes resistance rising); linezolid CBC if > 14 d + serotonin-syndrome screen; IVIG infusion reactions / IgA-deficiency / thrombosis surveillance (Stevens IDSA SSTI 2014; CDC)

Disposition

Current setting: outpatient — Recovery + desquamation course, recurrence counselling (avoid high-absorbency tampons in menstrual staph TSS — recurrence risk; nasal/vaginal S. aureus carriage decolonisation consideration), GAS-contact chemoprophylaxis discussion for severe invasive STSS, organ-recovery follow-up, return precautions (Stevens IDSA SSTI 2014; CDC)

Disposition criteria:
- Resolution: organ failure recovered + desquamation course complete + recurrence counselling delivered + residual source addressed — discharge from TSS-specific surveillance

Escalation triggers (move to higher acuity):
- Recurrent fever / rash / hypotension → ED + cross-route id.sepsis.core.v1 (recurrent TSS)
- Wound / nec-fasc complication → cross-route id.necrotising-fasciitis.core.v1
- Organ-recovery failure → specialist organ follow-up

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Toxic shock syndrome with hypotension (SBP < 90 mmHg / orthostatic drop / age-adjusted in children) + multi-organ involvement (≥ 3 organ systems staphylococcal / ≥ 2 streptococcal per CDC) — distributive/toxic shock; SSC Hour-1 bundle + cross-route id.sepsis.core.v1 with carryover (CDC TSS case definitions; SSC 2026)
- [LIFE_THREATENING] Streptococcal toxic shock syndrome with a necrotising soft-tissue infection (necrotising fasciitis / myositis — ≈ 50% of STSS) — EMERGENT surgical debridement is the dominant survival determinant; penicillin G + clindamycin + IVIG; cross-route id.necrotising-fasciitis.core.v1 (do NOT delay surgery for imaging) (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909)
- [LIFE_THREATENING] Rapidly progressive soft-tissue pain out of proportion ± hemorrhagic bullae / crepitus / anaesthesia + systemic toxicity — early clue of streptococcal TSS with necrotising fasciitis / myositis; EMERGENT surgical exploration (do NOT delay for imaging) + cross-route id.necrotising-fasciitis.core.v1 (Stevens IDSA SSTI 2014 PMID 24973422; Sartelli WSES/SIS 2021 PMID 34022909)

Citations

- IDSA SSTI Guideline (Stevens DL et al, Clinical Infectious Diseases 2014 — PMID 24973422; defines TSS empiric antibiotic + protein-synthesis-inhibitor [clindamycin] toxin suppression + IVIG Class IIa for streptococcal TSS + source-control logic) + CDC Toxic Shock Syndrome case definitions (staphylococcal: fever ≥ 38.9 °C + diffuse macular erythroderma + hypotension + ≥ 3-organ involvement + desquamation [late] + negative alternative serologies; streptococcal: group A streptococcus isolation [sterile site = confirmed, non-sterile = probable] + hypotension + ≥ 2 organ-system involvement) + Surviving Sepsis Campaign 2026 (distributive/toxic-shock resuscitation backbone — Hour-1 bundle, vasoactive titration, organ support) + Darenberg CID 2003 IVIG-in-STSS RCT (PMID 12884159 — underpowered, trend benefit) + Linnér CID 2014 IVIG-in-STSS observational cohort (PMID 24928291 — adjusted mortality OR ≈ 0.30) + Stevens JID 1988 clindamycin Eagle effect (PMID 2839555) + Sartelli WSES/SIS NF 2021 (PMID 34022909 — emergent debridement when STSS co-presents with necrotising soft-tissue infection) + Wong LRINEC CCM 2004 (PMID 15241098) + Rybak ASHP/IDSA vancomycin AUC 2020 (PMID 32191793) + Kumar CCM 2006 (PMID 16625125 — antibiotic-delay mortality) [PMID:24973422](https://pubmed.ncbi.nlm.nih.gov/24973422/)
- Cited evidence (PMID 12884159) [PMID:12884159](https://pubmed.ncbi.nlm.nih.gov/12884159/)
- Cited evidence (PMID 24928291) [PMID:24928291](https://pubmed.ncbi.nlm.nih.gov/24928291/)
- Cited evidence (PMID 2839555) [PMID:2839555](https://pubmed.ncbi.nlm.nih.gov/2839555/)
- Cited evidence (PMID 34022909) [PMID:34022909](https://pubmed.ncbi.nlm.nih.gov/34022909/)

Last reconciled with current guidelines: 2026-05-15.

References

IDSA SSTI Guideline (Stevens DL et al, Clinical Infectious Diseases 2014 — PMID 24973422; defines TSS empiric antibiotic + protein-synthesis-inhibitor [clindamycin] toxin suppression + IVIG Class IIa for streptococcal TSS + source-control logic) + CDC Toxic Shock Syndrome case definitions (staphylococcal: fever ≥ 38.9 °C + diffuse macular erythroderma + hypotension + ≥ 3-organ involvement + desquamation [late] + negative alternative serologies; streptococcal: group A streptococcus isolation [sterile site = confirmed, non-sterile = probable] + hypotension + ≥ 2 organ-system involvement) + Surviving Sepsis Campaign 2026 (distributive/toxic-shock resuscitation backbone — Hour-1 bundle, vasoactive titration, organ support) + Darenberg CID 2003 IVIG-in-STSS RCT (PMID 12884159 — underpowered, trend benefit) + Linnér CID 2014 IVIG-in-STSS observational cohort (PMID 24928291 — adjusted mortality OR ≈ 0.30) + Stevens JID 1988 clindamycin Eagle effect (PMID 2839555) + Sartelli WSES/SIS NF 2021 (PMID 34022909 — emergent debridement when STSS co-presents with necrotising soft-tissue infection) + Wong LRINEC CCM 2004 (PMID 15241098) + Rybak ASHP/IDSA vancomycin AUC 2020 (PMID 32191793) + Kumar CCM 2006 (PMID 16625125 — antibiotic-delay mortality) — PMID:24973422
Cited evidence (PMID 12884159) — PMID:12884159
Cited evidence (PMID 24928291) — PMID:24928291
Cited evidence (PMID 2839555) — PMID:2839555
Cited evidence (PMID 34022909) — PMID:34022909