A 23-year-old woman presents to the emergency department for evaluation of fever, lethargy, abdominal pain, and myalgias which developed over the past 24 hours. Vital signs are significant for a temperature of 102.1°F (38.9°C), blood pressure of 80/60 mmHg, and heart rate of 120 beats/min. Physical examination reveals warm, moist skin, a diffuse, macular erythematous rash, and a saturated tampon in the vaginal canal. Intravenous fluids are started, the tampon is removed, and blood cultures are sent.
E) Vancomycin, clindamycin, and cefepime
This patient shows signs of sepsis (fever, hypotension, tachycardia) and although the precise cause is unknown, her macular rash and multisystem organ involvement (abdominal pain, myalgias) in the context of prolonged tampon use suggests Staphylococcal toxic shock syndrome (TSS). Until the specific infectious agent is confirmed, the initial antibiotic regimen should consist of vancomycin, clindamycin, and cefepime, which offers broad coverage of gram-positive, gram-negative, and anaerobic organisms.
Answer choice A: Cefazolin and clindamycin, is incorrect. This combination is effective for treating toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus (MSSA). Until MSSA infection is confirmed, this regimen would be inadequate.
Answer choice B: Supportive care until cultures return, is incorrect. This patient is hemodynamically unstable and requires immediate empiric antibiotic therapy. Waiting for cultures to return puts her at risk of further multiorgan system damage.
Answer choice C: Vancomycin alone, is incorrect. For cases of sepsis due to Staphylococcus aureus, clindamycin is added for its ability to suppress bacterial toxin synthesis.
Answer choice D: Vancomycin and clindamycin, is incorrect. This combination is effective for treating toxic shock syndrome due to methicillin-resistant Staphylococcus aureus (MRSA). Although vancomycin alone is an adequate bactericidal treatment for MRSA, clindamycin is still used due to its ability to suppress toxin synthesis by S. aureus. Until the patient is hemodynamically stable, clindamycin should be continued.
Key Learning Point
Staphylococcal toxic shock syndrome is characterized by typical signs of sepsis (fever, hypotension) as well as diffuse macular erythroderma and signs of multisystem organ involvement. Until cultures indicate specific infectious agents, initial antibiotic therapy should offer broad coverage and may consist of vancomycin, clindamycin, and cefepime.
