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Epidemiology and Clinical Relevance of Toxic Shock Syndrome in US Children

Gaensbauer, James T., MD, MScPH*,†,‡; Birkholz, Meghan, MSPH; Smit, Michael A., MD, MSPH§; Garcia, Roger, MD; Todd, James K., MD†,‡

The Pediatric Infectious Disease Journal: December 2018 - Volume 37 - Issue 12 - p 1223–1226
doi: 10.1097/INF.0000000000002002
Original Studies

Introduction: It is important for clinicians to recognize the contribution of toxic shock syndrome (TSS) to the overall burden of pediatric septic shock because the clinical features, optimal therapy and prognosis differ from non-TSS septic shock.

Methods: We analyzed cases of pediatric septic shock reported to the Pediatric Health Information Systems database between 2009 and 2013 to define the clinical and demographic characteristics of pediatric TSS in the United States. Using a validated International Classification of Diseases, 9th revision, coding strategy, we identified patients with infectious shock among inpatients age 1–18 years and classified cases of staphylococcal and streptococcal TSS for comparison with non-TSS cases.

Results: Of 8,226 cases of pediatric septic shock, 909 (11.1%) were classified as TSS and 562 (6.8%) were possible TSS cases. Staphylococcal TSS represented the majority (83%) of TSS cases and occurred more commonly in females and at an older age. Compared with non-TSS septic shock, TSS had significantly lower fatality rates, disease severity and length of hospital stay and was present more often at the time of admission (P < 0.001 for each). Streptococcal TSS was associated with poorer outcomes than staphylococcal TSS. Treatment for TSS differed from non-TSS septic shock in use of more clindamycin, vancomycin and Intravenous Immunoglobulin and less need for vasopressors.

Conclusions: Results demonstrate a significant contribution of TSS to the burden of pediatric septic shock in the United States. The findings emphasize the importance of inclusion of TSS diagnostic and therapeutic considerations in sepsis treatment protocols for children.

From the *Pediatrics and Infectious Diseases, Denver Health Medical Center, Denver, Colorado

Pediatric Infectious Diseases, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado

Epidemiology, Children’s Hospital Colorado, Denver, Colorado

§Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island

Pediatric Intensive Care Medicine, Denver Health Medical Center, Denver, Colorado.

Accepted for publication January 8, 2018.

The authors have no funding or conflicts of interest to disclose.

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Address for correspondence: James T. Gaensbauer, MD, MScPH, 777 Bannock Street, Pavilion C, MC 0590, Denver, CO, 80204. E-mail:

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