Introduction

Hospital-acquired infections (HAIs), frequently referred to as nosocomial infections or healthcare-associated infections, are infections that patients get while undergoing medical care in a hospital.¹ These infections are either absent or incubating at the time of admission, and they usually appear 48 hours following admission.

HAIs are a serious threat to global healthcare systems and patient safety. In England alone, they impact approximately 300,000 people yearly and cost the NHS an estimated £1 billion annually.² A rare but potentially fatal illness known as toxic shock syndrome (TSS) occurs when toxins are generated by specific strains of bacteria, mainly Streptococcus pyogenes and Staphylococcus aureus.³

TSS symptoms often include:

• Sudden high fever (39 to 40.5°C)
• Hypotension (which can be refractory)
• Diffuse macular erythroderma
• Vomiting and diarrhea
• Muscle aches and pain
• Confusion or disorientation

With fatality rates ranging from 1–5% for staphylococcal TSS to as high as 50% for streptococcal TSS, the severity of TSS cannot be emphasised. This harsh reality highlights how critical early diagnosis and treatment are.³

Many factors make the connection between HAI and TSS especially pertinent. Due to compromised immune systems, invasive procedures, and exposure to several microorganisms, patients in healthcare settings are frequently at a higher risk of contracting infections.

TSS and other illnesses may occur from this increased susceptibility to HAIs.⁵ Skin and surgical site infections are frequently linked to TSS, particularly streptococcal TSS. There is a clear connection between HAIs and the possible emergence of TSS because surgical site infections are among the most prevalent forms of HAIs.⁶ 

TSS and HAIs may become more difficult to treat due to the growing issue of antibiotic-resistant bacteria in hospital settings.⁶ This could result in more serious consequences.

By comprehending the link between TSS and HAIs, healthcare settings can implement more potent preventative techniques.⁷ With appropriate infection control measures, many HAIs, including those that could result in TSS, are thought to be preventable.⁵

TSS and HAIs both have a major impact on medical expenses and prolonged hospital stays. Improving patient outcomes and allocating resources more effectively may result from addressing this relationship.⁵ This could lead to more efficient resource allocation and improved patient outcomes, ultimately benefiting both healthcare providers and patients.

Understanding HAIs

For efficient prevention and control, it is essential to comprehend the common forms of HAIs. About 20% of all HAIs are surgical site infections, making them one of the most common. These infections occur at the surgery site and can lead to serious complications if left untreated.⁸

Catheter-associated urinary tract infections (CAUTIs) are another significant concern, often resulting from prolonged use of urinary catheters.⁹ Similarly, central line-associated bloodstream infections (CLABSIs) are serious infections that can occur when bacteria enter the bloodstream through central line catheters.¹⁰ Ventilator-associated pneumonia (VAP) affects patients on mechanical ventilation.¹¹

HAIs are frequently caused by a variety of bacterial and fungal infections. Methicillin-resistant Staphylococcus aureus (MRSA) is, in particular, a common cause of many healthcare-associated infections (HAIs).¹² Another important infection that causes streptococcal toxic shock syndrome is Streptococcus pyogenes. Clostridium difficile, Pseudomonas aeruginosa, and other gram-negative bacteria are examples of common species.⁵

Several risk factors influence the emergence of HAIs, e.g. the risk of HAIs is greatly increased by extended hospital stays. According to one study, individuals who stayed in the hospital for more than eight days contract HAI.⁵ The risk of infection is also significantly increased by invasive procedures, such as the use of urinary catheters and central intravascular catheters.⁵ 

Critically ill patients frequently have immunocompromised conditions, which increase their vulnerability to HAIs. The connection between toxic shock syndrome (TSS) and HAIs is especially worrisome. Certain types of Streptococcus pyogenes and Staphylococcus aureus release toxins that cause TSS, a rare but potentially fatal illness. When surgical site infections or invasive procedures occur in a hospital setting, TSS can arise as a consequence of HAIs.¹²

Streptococcal TSS is often linked to skin and soft tissue infections and carries a much higher mortality rate of up to 50%.¹² The rapid progression and severity of TSS underscore the critical importance of preventing HAIs and promptly recognising and treating any signs of infection.

It is essential to implement prevention methods for HAIs and related consequences, such as TSS. These include using antibiotics sparingly to avoid the emergence of resistant strains, sterilising medical equipment appropriately, and rigorously adhering to hand hygiene guidelines.⁵ The danger of infection can also be considerably decreased by avoiding invasive devices and getting rid of them as soon as it is medically possible.

Overview of TSS

Toxins produced by specific bacterial strains, mainly Streptococcus pyogenes and Staphylococcus aureus, are the causes of TSS. The signs of the syndrome, which include a high temperature, hypotension, and a distinctive diffuse red skin rash, might appear rapidly.³

The crucial significance of TSS is highlighted by the speed at which it can develop into severe and persistent shock, which may result in numerous organ dysfunction. The occurrence of pathogenic organisms in healthcare settings makes the likelihood of TSS in hospital-acquired illnesses particularly concerning.

For example, surgical site infections and bloodstream infections linked to central lines are frequently caused by Staphylococcus aureus, especially methicillin-resistant strains (MRSA).¹³ Long hospital stays, the use of indwelling medical devices, invasive procedures and operations, and the immunocompromised conditions of many hospitalised patients are all factors that raise the risk of TSS in hospital settings.¹⁴

Linking HAIs to TSS

One crucial area of concern that emphasises the significance of strict infection control procedures in hospital settings is the connection between HAIs and TSS. There are usually two main mechanisms at play in the relationship between HAIs and TSS.

First, pathogenic microbes that can produce the toxins that cause TSS may be present in clinical settings. Patients, particularly those with weakened immune systems or extended hospital stays, may become colonised by these microorganisms.⁵

Second, these bacteria can enter through skin or mucosal barriers disrupted by invasive medical procedures and devices commonly used in hospital settings.^5,15

Potential sites for bacterial invasion include urine catheters, central venous catheters, and surgical incisions. These processes frequently cooperate to provide an environment favourable for the emergence of TSS.¹⁶ For example, a patient colonised with Staphylococcus aureus, which produces toxins, might not have any problems until they have surgery.

TSS may occur due to the surgery because it opens a channel for the bacteria to enter deeper tissues. Likewise, if a patient has germs on their skin that produce toxins, inserting a central line may allow these infections to enter the bloodstream directly.¹⁶

This connection between TSS and HAIs has important clinical practice consequences. Healthcare professionals need to be on the lookout for TSS symptoms, especially in patients who have recently had invasive operations or who have established risk factors. The quick development of TSS emphasises how crucial it is to identify and treat suspected HAIs as soon as possible.

Prevention and control of HAIs to reduce the risk of TSS

To lower the risk of TSS and enhance overall patient outcomes, it is imperative to prevent and control HAIs.

In hospital settings, infection control procedures are essential for reducing the risk of HAIs and, by extension, TSS. Hand hygiene is one of the most basic and efficient activities. To stop the spread of infections, healthcare personnel must frequently wash their hands before and after interacting with patients. This easy yet important step will greatly slow the spread of bacteria like Streptococcus pyogenes and Staphylococcus aureus that can cause TSS.¹⁷

Another crucial component of infection control is properly sterilising equipment.¹⁷ To stop harmful pathogens from colonising and spreading, healthcare facilities must make sure that all medical equipment and gadgets are properly cleansed and disinfected.¹⁸ This is especially crucial for intrusive devices like surgical instruments and catheters, which, if not properly sterilised, might provide entry routes for bacteria.

Monitoring of HAI outbreaks and early diagnosis are critical elements of an effective infection control plan. Healthcare facilities should implement robust surveillance systems to quickly identify such epidemics. Regular microbiological testing, infection rate analysis, and prompt investigation of any strange illness patterns or clusters may be necessary for this.¹⁸

The risk of TSS and HAIs can be decreased using patient care policies that avoid intrusive procedures. Healthcare professionals should carefully assess if each invasive surgery is necessary and, if feasible, look into less invasive options. Strict adherence to aseptic practices is essential when invasive operations are necessary to reduce the risk of infection.¹⁸

Along with these steps, healthcare facilities must give priority to educating and training all employees on infection control procedures. As early detection and management are essential in managing this potentially lethal infection, this involves raising awareness of the signs and symptoms of TSS.¹⁸

Recent advances

New approaches to prevent hospital-acquired infections (HAIs) and their propensity to cause serious consequences like toxic shock syndrome (TSS) have been made possible by recent research advancements.

These advancements present encouraging methods for managing, preventing, and detecting these potentially fatal illnesses early. The development of vaccinations that target the toxins generated by Staphylococcus aureus, the main cause of TSS, represents a major advancement in TSS prevention.²⁰

Clinical trials of a vaccine have produced promising outcomes. This vaccine is safe, well-tolerated, and highly immunogenic, according to phase 2 studies. Although efficacy trials are difficult because of the low frequency of TSS, serological data points to possible efficacy in preventing this serious illness.²¹

Additionally, new diagnostic techniques are being developed to identify microorganisms that produce toxins. For example, the Cdifftox plate assay combines the identification of active toxins with the isolation of Clostridium difficile strains in a single step. The time and effort needed for diagnosis are greatly decreased by this approach, which has demonstrated 99.8% accuracy in identifying microorganisms that produce toxins.²²

Summary

Hospital-acquired infections (HAIs) are those that patients acquire from a healthcare setting, like a hospital. It usually activates in 48 hours. Many symptoms like low blood pressure (hypotension), fever, and vomiting are associated with HAIs.

Toxic shock syndrome (TSS) is a condition caused by Streptococcus pyogenes and Staphylococcus aureus. It is characterised by low blood pressure and red skin rashes. Infection control becomes crucial for hospitals to keep HAIs and TSS separate.

Delayed stays at hospitals, especially in immunocompromised patients, allow it to happen. Infected surgical apparatus can be the culprits. 

Diverse strategies are needed to prevent HAIs and lower the risk of TSS. Effective infection prevention techniques are based on standard infection control measures, such as using personal protective equipment, washing your hands properly, and managing care equipment and the environment safely.

Even though there has been progress, ongoing attention, research, and action are necessary due to the ongoing threat posed by HAIs and their propensity to cause serious consequences like TSS.

We can drastically lower the prevalence of HAIs and TSS, which will eventually improve patient outcomes and save lives, by putting an emphasis on infection control, encouraging a culture of safety, and increasing public awareness.