›Vancomycin 25–30 mg/kg IV loading dose then 15–20 mg/kg IV every 8–12 hours
›Target trough 15–20 mcg/mL or AUC/MIC-guided dosing
›Use when MRSA risk factors present
›Plus clindamycin 600–900 mg IV every 8 hours
›Streptococcal TSS regimen
›Penicillin G plus clindamycin
›Penicillin G 4 million units IV every 4 hours
›IDSA recommendation for Group A Streptococcus
›Bactericidal against Streptococcus pyogenes
›Plus clindamycin 600–900 mg IV every 8 hours
›Suppresses M-protein and streptococcal toxin production
›Eagle effect — clindamycin superior in high bacterial burden
›Continue clindamycin for 5–7 days minimum
›Clindamycin resistance alternative
›Linezolid 600 mg IV every 12 hours
›Alternative when clindamycin resistance documented
›Also suppresses toxin production
›Unknown etiology broad-spectrum empiric regimen
›Vancomycin plus piperacillin-tazobactam plus clindamycin
›Vancomycin 25–30 mg/kg IV loading dose
›MRSA coverage
›Piperacillin-tazobactam 4.5 g IV every 6 hours
›Gram-negative and anaerobic coverage
›Clindamycin 600–900 mg IV every 8 hours
›Toxin suppression regardless of etiology
›De-escalate based on culture and sensitivity results
›Narrow when organism identified
›Intravenous immunoglobulin (IVIG)
›Indication for IVIG in TSS
›Refractory shock not improving with aggressive support and source control
›Neutralizes circulating superantigens
›Consider when vasopressor requirements escalating despite antibiotics
›IVIG dosing
›1–2 g/kg IV as single dose
›Repeat at 48 hours if insufficient response
›Streptococcal TSS primary evidence base
›Infuse over 6–12 hours
›Monitor for anaphylaxis
›IgA-deficient patients at risk for anaphylaxis
›Evidence level
›Class IIb recommendation based on observational data and small RCTs
›Mortality benefit most supported in streptococcal TSS
›Source control
›Removal of all foreign bodies
›Tampon, nasal packing, wound packing — immediate
›Do not delay antibiotics for source control
›Surgical debridement
›Necrotizing fasciitis — immediate operative debridement
›Abscess incision and drainage
›Class I recommendation — surgical source control concurrent with antibiotic therapy
›NSAID avoidance
›NSAIDs associated with increased severity of streptococcal TSS
›Particularly in children with varicella
›Avoid in all suspected TSS regardless of etiology
›Lung-protective ventilation if intubated
›ARDS network protocol
›Tidal volume 6 mL/kg ideal body weight
›Plateau pressure < 30 cmH2O
›PEEP titrated to oxygenation
›Renal replacement therapy
›Continuous RRT for AKI with fluid overload or severe acidosis
›Bridge to renal recovery — most TSS AKI reversible
›Initiate when creatinine rapidly rising or oliguria refractory
›DIC management
›Coagulopathy correction
›FFP for active bleeding with INR > 1.5
›Cryoprecipitate for fibrinogen < 1.5 g/L with bleeding
›Platelet transfusion for platelets < 50 x 10^9/L with active bleeding