Toxic Shock Syndrome - Vulvovaginal Infections

TOXIC SHOCK SYNDROME

Toxic shock syndrome (TSS) is a life-threatening, multisystemdisease caused by response to the toxins produced by strains of the bacterium S. aureus in susceptible patients. This rare condi-tion is associated with menstruation (although the incidence of menstrual TSS has dramatically decreased due to public aware-ness, the number of nonmenstrual cases of TSS has not declined).

Approximately 1% of women carry strains of staphylococcus ca-pable of producing the responsible toxin. Nonmenstrual TSS oc-curs after childbirth, after abortion, and in persons with bone and skin infections, postoperative infections, burns, mastitis, and varicella-related cellulitis. Sinusitis, tracheitis, pneumonia, and the presence of foreign bodies (eg, nasal packing, IUDs, contra-ceptive sponges) have been associated with nonmenstrual TSS.

Clinical Manifestations

In an otherwise healthy person, the onset of TSS occurs with a sudden fever (temperature is always at least 38.9° C [102° F]), chills, malaise, and muscle pain. Vomiting, diarrhea, hypoten-sion, headache, and signs suggesting early septic shock may de-velop. A red, macular rash similar to sunburn (diffuse, macular erythroderma) is a classic sign of TSS. In some patients, this rash appears first on the torso; in others, it is first seen on the hands (palms and fingers) and feet (soles and toes). Inflammation of mucous membranes also may occur. In 7 to 10 days, it desqua-mates (becomes scaly or peels). Myalgia and dizziness are common. Severe cases can result in acute respiratory distress syndrome (ARDS), and cardiac dysfunction may occur.

Assessment and Diagnostic Findings

Urine output decreases, and the blood urea nitrogen level increases, often resulting in disorientation. Laboratory tests also reveal leuko-cytosis and elevated bilirubin. Uncontrollable hypotension and dis-seminated intravascular coagulopathy (DIC) may also occur. The clinical picture of septic shock  results. Res-piratory distress may develop as a result of pulmonary edema. If ARDS occurs, the outlook is grave. About 2% to 3% of patients with TSS die of complications.

Medical Management

Treatment includes elimination of the source of the infection; ad-ministration of fluids, vasopressors, and antibiotic agents; and ir-rigation of the presumed site of infection. The patient is placed on bed rest, and the treatment plan is directed primarily at con-trolling the infection and restoring circulating blood volume.

Antibiotic therapy is based on the results of blood, urine, and other cultures. Antistaphylococcal agents are prescribed. Anti-biotic therapy has not been found to affect the course of TSS but to prevent recurrence.

In cases of respiratory distress, oxygen therapy is instituted; if signs of acidosis appear, sodium bicarbonate is administered. Cal-cium is prescribed for hypocalcemia. A Swan-Ganz catheter (for hemodynamic monitoring) and intravenous dopamine may be used to manage shock. The entire treatment plan, including strategies directed toward emotional and psychological concerns, is adjusted according to each patient’s condition, which may vary from mild to acute.

Nursing Management

The patient with suspected TSS is assessed for factors known to be associated with it: use of tampons (absorbency, length of time a tampon was retained before changing it, trauma that may have occurred with its insertion) or diaphragms and the presence of other risk factors. Additionally, the patient is assessed and treated for complications associated with TSS (DIC and septic shock). The patient is observed for hematomas, petechiae, oozing from needle and infusion sites, cyanosis, and coolness of the nose, finger-tips, and toes. The patient is further observed for skin changes and fluid intake and loss; these data assist in evaluating hydration and kidney function. The patient with TSS is usually critically ill and is cared for in the intensive care unit to facilitate constant monitoring and assessment for the onset of complications and re-sponse to treatment. Because of the likelihood of severe septic shock, the patient is monitored closely for changes in vital signs, level of consciousness and responsiveness to stimuli, and labora-tory values, including arterial blood gases. The patient’s response to prescribed medications and fluids is also evaluated.

Teaching Patients Self-Care. 

Because of the lengthy period thatis required for recovery from TSS, the patient must be prepared to increase participation in self-care activities gradually. The pa-tient and caregiver need instructions about detection and pre-vention of the complications associated with immobility. The nurse also explains the possible causes of TSS and steps to take to prevent its recurrence. Because use of tampons during menstru-ation has been linked with TSS, women who have had TSS should not use tampons. If a diaphragm is used, it should not be left in place longer than 8 to 10 hours. Using the diaphragm or cervical cap during menses or in the first 3 months postpartum is also dis-couraged. The risk of developing TSS increases any time a woman bleeds vaginally (ie, during menses and postpartum). Be-cause of the risk of TSS, all women who use tampons should be informed that they must be changed frequently (every 4 hours) and inserted carefully to avoid abrasions (applicators with rough edges should be avoided). Use of superabsorbent tampons is not recommended.