Staphylococcal Toxic Shock Syndrome 2000–2006: Epidemiology, Clinical Features, and Molecular Characteristics

Abstract

IntroductionCirculating strains of Staphylococcus aureus (SA) have changed in the last 30 years including the emergence of community-associated methicillin-resistant SA (MRSA). A report suggested staphylococcal toxic shock syndrome (TSS) was increasing over 2000–2003. The last population-based assessment of TSS was 1986.MethodsPopulation-based active surveillance for TSS meeting the CDC definition using ICD-9 codes was conducted in the Minneapolis-St. Paul area (population 2,642,056) from 2000–2006. Medical records of potential cases were reviewed for case criteria, antimicrobial susceptibility, risk factors, and outcome. Superantigen PCR testing and PFGE were performed on available isolates from probable and confirmed cases.ResultsOf 7,491 hospitalizations that received one of the ICD-9 study codes, 61 TSS cases (33 menstrual, 28 non-menstrual) were identified. The average annual incidence per 100,000 of all, menstrual, and non-menstrual TSS was 0.52 (95% CI, 0.32–0.77), 0.69 (0.39–1.16), and 0.32 (0.12–0.67), respectively. Women 13–24 years had the highest incidence at 1.41 (0.63–2.61). No increase in incidence was observed from 2000–2006. MRSA was isolated in 1 menstrual and 3 non-menstrual cases (7% of TSS cases); 1 isolate was USA400. The superantigen gene tst-1 was identified in 20 (80%) of isolates and was more common in menstrual compared to non-menstrual isolates (89% vs. 50%, p = 0.07). Superantigen genes sea, seb and sec were found more frequently among non-menstrual compared to menstrual isolates [100% vs 25% (p = 0.4), 60% vs 0% (p<0.01), and 25% vs 13% (p = 0.5), respectively].DiscussionTSS incidence remained stable across our surveillance period of 2000–2006 and compared to past population-based estimates in the 1980s. MRSA accounted for a small percentage of TSS cases. tst-1 continues to be the superantigen associated with the majority of menstrual cases. The CDC case definition identifies the most severe cases and has been consistently used but likely results in a substantial underestimation of the total TSS disease burden.

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…Shortly thereafter, S. aureus TSS became linked with superabsorbent tampons in menstruating women in the 1980s (801,802), reaching an annual infection rate of 13.7 per 100,000 menstruating women (803). After the removal of highly absorbent tampons from the market, the annual incidences of S. aureus TSS declined to 1 per 100,000 menstruating women and 0.3 per nonmenstruating persons (804)(805)(806). The incidence of S. aureus TSS has remained stable since that time, with the current annual incidences reported to be 0.69 per 100,000 menstruating women and 0.32 per 100,000 total population (804).…”

Physiology and Pathology of Multidrug-Resistant Bacteria: Antibodies- and Vaccines-Based Pathogen-Specific Targeting

“…aureus is a round-shaped, facultative anaerobe, which can produce an array of superantigens (SAgs), including staphylococcal exotoxins, enterotoxins, and toxic shock syndrome toxin 1 (TSST-1). These toxins exert their hyper-stimulatory properties and cause food poisoning, toxic shock syndrome, acute lung diseases, and autoimmune diseases [7][8][9][10]. The superantigenicity of SAgs is largely achieved by the activation of APCs and T cells, leading to a massive release of cytokines, including IL-1β, IL-6, and TNFα [11].…”

Staphylococcal Enterotoxins, Stayphylococcal Enterotoxin B and Bioterrorism

“…Since its discovery, TSS had been considered a rare, but often fatal disease. After removal of absorbent tampons from the market and efforts to inform the public about TSS, incidences of menstrual TSS dropped from 13.7% to 0.3% per 100,000 individuals in the U. S. Since 1986, reported incidences of TSS in the U.S. have remained stable with the annual incidence rate around 0.32%-0.52% per 100,000 people (DeVries, et al, 2011;Haijeh et al, 1996). Several reasons may account for the disease's rarity.…”

“…Supportive care should be aggressive and monitored carefully. Length of hospitalization may vary between 5 and 11 days (DeVries et al, 2011).…”

“…Human activated protein C (hAPC) was approved for patients in severe septic shock, and had been used to treat TSS (DeVries et al 2011). On October 25, 2011, Eli Lilly withdrew Xigris (hAPC) because more in depth clinical trials indicated that drug did no better than a placebo in reducing mortality (http://www.medscape.com/viewarticle/752169).…”