Toxic Shock Syndrome

Toxic shock syndrome may occur following a prodromal period of 24-48 hrs with symptoms of diarrhoea,
vomiting, general malaise and pyrexia. The shock phase tends to develop D3/D4, there may be a drop
observed in total WCC especially neutrophils and also in haemoglobin. TSSTI titres may be useful in making the
diagnosis, the desquamation occurs in the recovery phase(NB TSST1 may not be isolated despite clinical
appearance of toxic shock syndrome) TSS may develop following a small burn.

ANTIBIOTICS-preferably antibiotics should not be commenced until sensitivities back. If clinical condition
doesn't allow this then

First line antibiotics Day 2 - day 7 - most common organisms are Staph aureus and Streptococcus(NB strep
pyogenes requires aggressive treatment)

Flucloxacillin 50 mg/kg qds and Penicillin 50mg/kg qds Evidence of Gram neg organisms add in gentamicin

Gentamicin 7mg/kg od

Monitor levels closely as renal clearance and volume of distribution may be altered significantly in burns
patients - I hr post > l0mcg/ml, 12-16 hrs post 0.2 1 mcg/ml,

Antibiotics should be continued for 5 days if cultures negative and 7 days if cultures positive.

Any antibiotic changes should be based on culture results and be made after discussion with
PICU/Plastics/Microbiology/Infectious Diseases Consultant

Week 2

If become septic and unable to wait for swab/culture results in week 2 onwards post

burn, the following should be started

Tazocin 115 mg/kg bd if child <2/12 tds if > 2/12 and Gentanticin 7mg/kg/d od

Central intravascular catheters and arterial lines should be changed every 48hrs with guidewire unless
evidence of inflammation at the site or positive cultures - usually staph epidermidis. They should be resited
every 72 hrs and lines sent for C&S.

An infected central line should receive vancomycin pro and post removal if peripheral

cultures are negative

Vancomycin 20mg/kg 12 hourly Aim for trough 6-10 mcg/ml Peak 25 - 40 mcg/ml

Careful monitoring of levels required, trough levels correlates with potential toxicity

and therapeutic efficacy

MRSA surveillance - weekly swabs.

Unexplained pyrexia consider UTI, CMV infection, bronchopneumonia. Antibiotic courses should be limited to
minimum and antibiotics targeted specifically.
Week 3 onwards

Organisms that should be considered are candida, CMV and resistant organisms

isolated on the unit e.g Acinetobacter, Pseudomonas, Strep Faccalis.

Antibiotics should only be started following discussion with a Consultant microbiologist or infectious diseases
consultant