Introduction

Toxic shock syndrome (TSS) is a serious health condition caused by a bacterial infection due to toxins released by the bacteria. Although commonly associated with infections caused by tampons that are not frequently changed, during the menstrual cycle, it can also occur in other circumstances i.e. after surgery. Minimising the risk of bacterial infection and preventing sepsis remains a vital goal of every procedure that compromises the barrier integrity of the skin. Especially in immunocompromised individuals that cannot initiate a proper immune response against bacterial infections; preventing, monitoring and treating TSS is key for improving patient health care outcomes. 

What is it

Toxic Shock Syndrome (TSS) is caused by the toxins produced by a bacterial infection of soft tissues, specifically Staphylococcus aureus and Staphylococcus pyogenes. These bacteria cause an infection and release toxins that travel through the blood to organs. The bacterial toxins produced are also known as superantigens as they trigger an intense proinflammatory response that can be associated with shock, organ failure and death.¹ 

Symptoms

• Fever 
• Rash on the soles of the feet
• Redness in the throat, mouth and eyes
• Low blood pressure
• Nausea, vomiting and diarrhoea
• Low blood pressure
• Seizures 
• Disorientation

Post-operation bacteria pose a significant TSS risk. During surgery, the skin barrier is broken to gain access to the soft tissue and other parts of the body to conduct a procedure. This ultimately leads to a vulnerability in the body’s defense system as once the barrier is compromised, opportunistic infections can occur.
So, early diagnosis is important in managing symptoms and treatment as delayed treatment can lead to permanent damage of the infected tissue and in severe cases death.  

Overview of toxic shock syndrome

Causes and risk factors

Staphylococcus aureus and Streptococcus pyogenes and other bacteria that cause TSS, make up part of the normal microbiome that is present on the skin. So, when the skin barrier is broken during surgery, during immunosuppression the bacteria that is usually on the outside, has an opportunity to enter into the body through the wounds. This causes a massive inflammatory response because the protective immune cells that sit underneath the skin barrier perceive these bacteria as foreign and will attempt to neutralise and eliminate them to protect the body. 

Symptoms and clinical presentation

Clinical presentation of symptoms can occur quickly with organ failure being reported as early as 8-12 hours after symptomatic presentation.²

Diagnosis criteria

Diagnosis can be made in the laboratory using certain markers as indicators for infection such as TSS.

Prevention strategies

Pre-operative measures

Understanding risk factors that can predispose someone to infection are important in taking precautionary measures. Low blood pressure, diabetes, and immune dysfunction caused by genetic conditions or medicinal use are important to consider before proceeding with operations. 

Besides good clinical practice, there are other factors to be considered which may limit the likelihood of TSS. 

• Sterile environment- ensuring that the operating procedural room is clean
• Sterile surgical equipment
• Good surgery practice is also important 
• Taking care to prevent cross-contamination
• Ensuring all surgical equipment is removed before suturing the site that was compromised
• Proper drainage for wounds are important measure that should be taken into consideration
• Prophylactic antibiotics to reduce the risk of TSS
• Risk assessments to acquire necessary information regarding the patient and take appropriate measures
• Utilise the risk assessment for decision-making regarding antibiotic, probiotics, fluid treatment, adjunctive therapy or further monitoring post-operatively

Post-operative measures

• Source control is a term used to ensure that the site where the operation was performed remains clean and has no swelling or signs of an infection
• Postoperative monitoring - recognising signs of an infection early is important in preventing severe damage or development to multiorgan failure
• If the risk is high for TSS, performing bacterial swabs and sending it for culture for bacterial diagnosis will help in early detection and subsequent antibacterial administration if required

Management of post-operative TSS

• Early recognition of symptoms
• Administration of broad-spectrum antibiotics to limit infection 
• Administration of fluids to combat the fever and loss of liquid
• Oxygenation to ensure the proper functioning of organs 
• Medication to combat toxins released by bacterial infections reduces organ damage and prevents further organ damage
• Monitoring within appropriate areas such as intensive care units where utmost care and attention to changes in vital organ function can be monitored
• Maintenance of proper blood pressure to combat symptoms of low blood pressure
• Administration of intravenous immunoglobulins (IVIG) as adjunctive therapy²

Challenges and future directions

Prevention and timely diagnosis remain key to managing TSS and preventing death. Implementing health care practices as a compulsory code of conduct for compliance is important to reduce post-operative infections. In addition, this also reduces the financial burden on public health services and improves patient care.

There are many avenues currently undergoing research to improve health care for patients. Vaccine development, bacterial sensors on wound care, prophylactic antibiotics, antitoxin administration, faster and improved diagnostic procedures such as polymerase chain reaction (PCR) and sequencing, medicines to combat biofilm formation and other avenues are being explored to reduce the prevalence of TSS.

Emerging research and innovations

• The development of vaccines that target specific surface proteins of the causative bacteria to prevent infection 
• Advanced diagnostic tools such as PCR tests to determine which bacterial group is causing the infection and the appropriate antibiotic administration
• Strategies to reduce the formation of biofilm by infecting bacteria such as antibacterial wound care products for post-operative care

Conclusion

TSS was previously thought to be exclusive to tampon usage during menstrual cycles. However, it has also been associated with surgery, wounds, minor operations, aesthetic operations such as liposuction,³ skin grafts⁴ and biopsies. Early detection and monitoring for the presentation of symptoms associated with TSS is vital for early treatment, and administration of antibiotics, fluid and adjunctive therapy to prevent, in severe cases, death. Continued efforts in wound healing, such as special gauze that has microbial sensors to detect bacterial toxins and release antitoxins, remain important to improve health care outcomes.