(1642) Evaluation of Intravenous Immune Globulin Use for Suspected Toxic Shock Syndrome

Introduction: There has been an increase in invasive Group A Streptococcus (GAS) infections. One of the more severe complications of GAS is toxic shock syndrome (TSS) which is associated with significant morbidity and mortality. Intravenous immune globulin (IVIG) may be used to mitigate TSS. Previous data is mixed regarding the efficacy and safety of IVIG for this indication and there are no reports describing the impact of IVIG on circulatory shock. The aim of this study is to describe the impact of IVIG on TSS in patients with invasive GAS or other gram-positive infection.

Methods: This is a single-center, retrospective analysis of adult patients who received IVIG for suspected TSS secondary to GAS or other gram-positive infections at a large academic medical center between 1/31/2021 and 5/31/2024. The primary endpoint is change in vasopressor dose after administration of IVIG. Secondary endpoints include describing the timeline of therapeutic interventions in relation to IVIG administration, cost of IVIG, adverse events including new venous thromboembolism (VTE) or infection after IVIG, and discharge disposition.

Results: Twenty-six encounters were included in this study in 25 unique patients. Median age was 65 (IQR 37-72) years, 31% were female, and median SOFA score was 13 (IQR 9-16) on admission. Patients commonly presented with bacteremia (63%), necrotizing soft tissue infection (41%), and/or skin/soft tissue infection (22%). GAS grew in most of the cultures (70%). Three patients were not receiving vasopressor support at time of IVIG administration. In the other 23 patients, median vasopressor dose prior to IVIG administration was 0.54 (IQR 0.21-0.84) mcg/kg/min norepinephrine equivalents. In patients that remained alive, the median dose 1 (n=22) and 6 (n=19) hours after administration was 0.37 (IQR 0.22-0.72) and 0.3 (IQR 0.15-0.54) mcg/kg/min norepinephrine equivalents respectively. New VTE events occurred in 18.5% while a new infection was treated in 30%. Mortality at 30 days was 37%.

Conclusions: Median vasopressor dose declined after IVIG administration although mortality remained high. Potential adverse effects of VTE events and new infection after IVIG administration occurred frequently which prompts further consideration of the potential benefit of IVIG for suspected TSS.