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.
Highlights
Circulating strains of Staphylococcus aureus (SA) have changed in the last 30 years including the emergence of community-associated methicillin-resistant SA (MRSA)
Among the 43 cases from 2000–2003, the toxic shock syndrome (TSS)-specific code was more likely to be used on menstrual cases [22/23, (96%)] compared to non-menstrual cases [16/20, (80%), p = 0.17]
The total number of TSS cases identified over years 2000–2006 was 61
Summary
Circulating strains of Staphylococcus aureus (SA) have changed in the last 30 years including the emergence of community-associated methicillin-resistant SA (MRSA). A syndrome of fever, myalgias, sore throat, edema, scarlitiniform rash, and desquamation associated with Staphylococcus aureus (SA) infection was first described in 1927, and in 1978 Todd et al coined the term staphylococcal toxic shock syndrome (TSS) [1,2]. By 1980, young menstruating women using high absorbency tampons were identified as a high risk group, with cases observed in men and non-menstruating women [3,4]. The estimated incidence of TSS in 1980 among young menstruating women was 13.7 per 100,000 persons [7]. In 1986, the overall case fatality rate was estimated to be 4%, with young women as the highest risk group (median age, 25 years) [9]. Since 1986, there has not been population-based active surveillance to assess the incidence or disease burden of TSS
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