Prognostic factors for streptococcal toxic shock syndrome: systematic review and meta-analysis

• Published in: BMJ open 2022-12, Vol.12 (12), p.e063023
• Main Authors: Bartoszko, Jessica J, Elias, Zeyad, Rudziak, Paulina, Lo, Carson K L, Thabane, Lehana, Mertz, Dominik, Loeb, Mark
• Format: Article
• Language: English
• Subjects: bacteriology; Clindamycin - therapeutic use; Epidemiology; general medicine (see internal medicine); Humans; Immunoglobulins, Intravenous; Infectious Diseases; Medical prognosis; Meta-analysis; Mortality; Prognosis; Sepsis; Shock, Septic - drug therapy; Streptococcal Infections - diagnosis; Streptococcal Infections - drug therapy; Streptococcus infections; Streptococcus pyogenes; Systematic review
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2022-063023

ObjectivesTo quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS).DesignSystematic review and meta-analysis.Data sourcesMEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies.Eligibility criteriaPairs of reviewers independently screened potentially eligible studies of patients with Group A Streptococcus-induced STSS that quantified the association between at least one prognostic factor and outcome of interest.Data extraction and synthesisWe performed random-effects meta-analysis after duplicate data extraction and risk of bias assessments. We rated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.ResultsOne randomised trial and 40 observational studies were eligible (n=1918 patients). We found a statistically significant association between clindamycin treatment and mortality (n=144; OR 0.14, 95% CI 0.06 to 0.37), but the certainty of evidence was low. Within clindamycin-treated STSS patients, we found a statistically significant association between intravenous Ig treatment and mortality (n=188; OR 0.34, 95% CI 0.15 to 0.75), but the certainty of evidence was also low. The odds of mortality may increase in patients ≥65 years when compared with patients 18–64 years (n=396; OR 2.37, 95% CI 1.47 to 3.84), but the certainty of evidence was low. We are uncertain whether non-steroidal anti-inflammatory drugs increase the odds of mortality (n=50; OR 4.14, 95% CI 1.13 to 15.14; very low certainty). Results failed to show a significant association between any other prognostic factor and outcome combination (very low to low certainty evidence) and no studies quantified the association between a prognostic factor and morbidity post-infection in STSS survivors.ConclusionsTreatment with clindamycin and within clindamycin-treated patients, IVIG, was each significantly associated with mortality, but the certainty of evidence was low. Future research should focus on morbidity post-infection in STSS survivors.PROSPERO registration numberCRD42020166961.