A 34-year-old woman, gravida 2 para 2, comes to the emergency department due to a 2-day history of fever, rash, and focal perineal pain. The patient was discharged from the hospital 10 days ago after an uncomplicated spontaneous vaginal delivery at 38 weeks gestation. She had a second-degree perineal laceration that was repaired with suture. The patient has been using a perineal pad, but no intravaginal packing after delivery. She has no chronic medical conditions and no medication allergies. Temperature is 40 C (104 F), blood pressure is 86/54 mm Hg, pulse is 132/min, and respirations are 24/min. The neck is supple. Pulmonary examination reveals bilateral crackles. The abdomen is soft and nontender. A diffuse macular rash is present over the trunk. On pelvic examination, the perineal laceration is tender, but there is no redness or swelling. The uterus is nontender on bimanual examination. Leukocyte count is 20,400/mm³ with 95% neutrophils. Which of the following is the most appropriate pharmacotherapy for this patient?

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11ec25c8_da06_5e8f_bc81_a3d0d57c4df6_MD0003_00 This patient with high fever, hypotension, and a diffuse macular rash (that may eventually involve the palms and soles) most likely has toxic shock syndrome (TSS). Other features of TSS can include headache, vomiting, profuse diarrhea, and mucous membrane hyperemia or ulceration. Most cases of TSS are caused by Staphylococcus aureus and are associated with retained foreign material (eg, tampon, nasal or vaginal packing); however, TSS can also occur with surgical or postpartum wound infection, as in this patient with a recent perineal laceration repair. Disease occurs due to the release of toxic shock syndrome toxin-1, an exotoxin that acts as a superantigen and causes an exaggerated immune response, leading to leukocytosis, multiorgan failure (eg, altered mentation, bilateral crackles), and shock (eg, hypotension, tachycardia), as in this patient. Treatment is with supportive therapy (eg, fluid replacement) and antistaphylococcal antibiotics; the most used combination is clindamycin plus vancomycin. Vancomycin has bactericidal activity against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), and clindamycin is highly effective at inhibiting TSS exotoxin production. (Choice A) Ceftriaxone, a third-generation cephalosporin, is typically used to treat gram-negative infections (eg, Neisseria meningitidis) that are resistant to beta-lactams. Although meningococcal meningitis can present with fever, patients typically have meningeal signs (eg, neck stiffness) and a petechial, rather than a macular, rash. In addition, this patient's recent perineal laceration makes TSS more likely. (Choice B) Ceftriaxone plus azithromycin (a macrolide) is typically used for the empiric treatment of acute cervicitis due to Neisseria gonorrhoeae (gram-negative) and Chlamydia trachomatis (an obligate intracellular gram-negative). This patient has no tenderness on bimanual examination, making acute cervicitis unlikely. Ceftriaxone and azithromycin have poor gram-positive coverage and are inappropriate in this patient with TSS. (Choice C) Doxycycline, a tetracycline, is typically used for gram-negative intracellular bacteria (eg, Rickettsia rickettsii, Chlamydia trachomatis) because of its ability to concentrate intracellularly. Although R rickettsii (ie, Rocky Mountain spotted fever) can cause fever and a rash, the rash is classically petechial and begins on the wrists and ankles before spreading to the trunk. (Choice D) Penicillin plus metronidazole (used for anaerobic bacteria) is inappropriate in the management of TSS, particularly in this recently hospitalized patient with possible MRSA resistant to penicillins. Educational objective: Toxic shock syndrome, caused by Staphylococcus aureus bacteremia and associated exotoxin release, typically presents with fever, hypotension, tachycardia, and a diffuse, red, macular rash. Treatment includes fluid replacement and antibiotic therapy with clindamycin plus vancomycin. References: Postpartum methicillin-resistant Staphylococcus aureus toxic shock syndrome caused by a perineal infection. (http://www.ncbi.nlm.nih.gov/pubmed/30363971) Lesson of the month 2: toxic shock syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/24889583)

A 34-Year-Old Woman, Gravida 2 Para 2, Comes to the Emergency