Severe group A streptococcal infection and streptococcal toxic shock syndrome

Purpose: To review the literature on group A streptococcal toxic shock synd rome, (STSS). Data source: Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also se arched using key words intravenous immunoglobulin, (IVIG) and group A strep tococcus, (GAS); and group A streptococcus and antibiotic therapy. Other re ferences were included in this review if they addressed the history. microb iology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed we re also considered. Articles on the foregoing topics were included regardle ss of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically sea rched. Principal findings: Reports of invasive GAS infections have recently increa sed. Invasive GAS infection is associated with a toxic shock syndrome, (STS S), in 8 - 14% of cases. The STSS characteristically results in shock and m ulti-organ failure soon after the onset of symptoms, and is associated with a mortality of 33 - 81%. Many of these patients will require extensive sof t tissue debridement or amputation in the operating room, on an emergency b asis. The extent of tissue debridement required is often underestimated bef ore skin incision. Conclusions: Management of STSS requires volume resuscitation, vasopressor/ inotrope infusion, antibiotic therapy and supportive care in an intensive c are unit, usually including mechanical ventilation. Intravenous immunoglobu lin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic manage ment of patients with septic shock.