Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android

For further information, see CMDT Part 33-04: Staphylococcus aureus Infections

Key Features

  • Multiple organisms that can cause toxic shock syndrome (TSS) include

    • Staphylococcus aureus

    • Streptococcus

    • Certain Clostridium species (C perfringens, C sordellii)

Staphylococcus aureus

  • Strains of staphylococci may produce toxins that can cause three important entities

    • Scalded skin syndrome, typically in children, or bullous impetigo in adults

    • TSS

    • Enterotoxin food poisoning

  • Although originally associated with tampon use, any focus (eg, nasopharynx, bone, vagina, rectum, abscess, or wound) harboring a toxin-producing S aureus strain can cause TSS

  • Fatality rates may be as high as 15%

Streptococcal infection

  • Any streptococcal infection—and necrotizing fasciitis in particular—can cause TSS

  • TSS is due to pyrogenic erythrotoxin, a superantigen that stimulates massive release of inflammatory cytokines believed to mediate the shock

  • Invasive disease

    • Risk factors are age (very young or older persons) and underlying medical conditions

    • Bacteremia occurs in most cases

  • Mortality rates can be up to 80%

Clostridium sordellii

  • C sordellii is a rare cause of endometritis and TSS following childbirth

  • Fatal cases of uterine infection following medically induced abortion with mifepristone have been reported

Clinical Findings

S aureus

  • Toxic shock is characterized by abrupt onset of high fever, vomiting, and watery diarrhea

  • Sore throat, myalgias, and headache are common

  • A diffuse macular erythematous rash and nonpurulent conjunctivitis are common, and desquamation, especially of the palms and soles, is typical during recovery

Streptococcal TSS

  • Invasion of skin or soft tissues

  • Acute respiratory distress syndrome

  • Kidney failure

  • Skin rash and desquamation may not be present

C sordellii

  • Sudden onset after medical abortion; may be within 4–5 days of ingestion of mifepristone

  • Abdominal pain

  • Absence of fever

  • Infection appears to be limited to the uterus, which shows

    • Necrosis

    • Edema

    • Hemorrhage

    • Acute inflammatory changes


S aureus

  • Blood cultures classically are negative because symptoms are due to the effects of the toxin and not to the invasive properties of the organism

C sordellii

  • Tachycardia, severe hypotension, capillary leak syndrome with edema

  • Profound leukocytosis, hemoconcentration


S aureus

  • Rapid rehydration

  • Antistaphylococcal antibiotics (eg, parenteral nafcillin or oxacillin or, in the penicillin allergic patient, clindamycin)

  • Management of kidney or heart failure

  • Removal of sources of toxin (eg, removal of tampon, drainage of abscess)

  • Intravenous clindamycin, 900 mg every 8 hours, is often added to inhibit toxin production

  • Intravenous immune globulin may be considered, although there are limited data compared with streptococcus TSS

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.