A 57-year-old man is brought to the emergency department by his wife with confusion. He was seen in the emergency department 2 days ago for profuse epistaxis. His primary care provider was concerned and had advised him to go to the hospital, as the patient is on warfarin for atrial fibrillation. However, his bleeding resolved with pressure and nasal packing. Upon presentation to the ED today, his temperature is 97.6°F (36.4°C), blood pressure is 64/33 mmHg, pulse is 160/min, respirations are 32/min, and oxygen saturation is 100% on room air. Physical exam reveals an obtunded man who cannot answer questions. A dark, purpuric rash is noted on his torso and extremities. The patient’s nasal packing is removed with no further bleeding. The patient is given IV fluids and blood cultures are drawn. Which of the following should be administered first?
Penicillin
Piperacillin-tazobactam
Meropenem
Clindamycin
Clindamycin
This patient is presenting with nasal packing, hypotension, tachycardia, a dark, purpuric rash, and confusion, which are concerning for toxic shock syndrome. The most important initial step in management is to administer clindamycin.

Toxic shock syndrome is a life-threatening diagnosis caused by Streptococcus pyogenes or Staphylococcus aureus and occurs commonly secondary to retained tampons or nasal packing. Patients are critically ill and require immediate management with fluids, vasopressors, and blood cultures. Source control is imperative, and the foreign body causing the infection must be removed. Next, broad-spectrum antibiotics should be started immediately. Clindamycin is often preferred as the first agent as this lincosamide antibiotic not only covers Staphylococcus aureus and Streptococcus pyogenes, but also has the theoretical benefit of suppressing toxin production. Further management is centered on fluid administration, vasopressors, and monitoring and care in an ICU setting as these patients are typically critically ill.

Russell and Pachorek review the treatments for toxic shock syndrome. They note that clindamycin is particularly important in toxic shock syndrome that is complicated by toxin production. They recommend that administration may reduce toxin production and could improve outcomes.

Incorrect Answers:
Answer B: Meropenem is a broad-spectrum antibiotic that covers most organisms except for MRSA. It is generally not used as a first-line agent unless the patient has allergies to other antibiotics or the infectious organism is only sensitive to this agent. Even in toxic shock syndrome, it would not be used as a first-line agent.

Answer C: Penicillin may be used for infections such as streptococcal pharyngitis, which presents with a sore throat, fever, and tonsillar exudates. It is a relatively weaker antibiotic and would not be used in a critically ill patient with toxic shock syndrome.

Answers 4 & 5: Piperacillin-tazobactam and vancomycin represent a powerful broad-spectrum regimen of antibiotics that covers gram-positives, gram-negatives, Pseudomonas aeruginosa, and anaerobes (piperacillin-tazobactam) as well as further gram-positive coverage and MRSA (vancomycin). Though this is a potent antibiotic combination, neither of these takes priority over clindamycin given the possible benefit of toxin suppression from clindamycin. In this patient, clindamycin and piperacillin-tazobactam would be an appropriate antibiotic regimen.

Bullet Summary:
Clindamycin may suppress toxin production and should be given early in toxic shock syndrome.