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

Jessica J Bartoszko; Zeyad Elias; Paulina Rudziak; Carson K L Lo; Lehana Thabane; Dominik Mertz; Mark Loeb

doi:10.1136/bmjopen-2022-063023

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

BMJ Open. 2022 Dec 1;12(12):e063023. doi: 10.1136/bmjopen-2022-063023.

Authors

Jessica J Bartoszko¹, Zeyad Elias², Paulina Rudziak³, Carson K L Lo⁴, Lehana Thabane^{1

5}, Dominik Mertz^{1

4}, Mark Loeb^{6

7}

Affiliations

¹ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.
² Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
³ Department of Biology, Western University, London, Ontario, Canada.
⁴ Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
⁵ Departments of Anesthesia and Pediatrics, McMaster University, Hamilton, Ontario, Canada.
⁶ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada loebm@mcmaster.ca.
⁷ Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.

Abstract

Objectives: To quantify the prognostic effects of demographic and modifiable factors in streptococcal toxic shock syndrome (STSS).

Design: Systematic review and meta-analysis.

Data sources: MEDLINE, EMBASE and CINAHL from inception to 19 September 2022, along with citations of included studies.

Eligibility criteria: Pairs 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 synthesis: We 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.

Results: One 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.

Conclusions: Treatment 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 number: CRD42020166961.

Keywords: bacteriology; epidemiology; general medicine (see internal medicine).

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Clindamycin / therapeutic use
Humans
Immunoglobulins, Intravenous
Prognosis
Shock, Septic* / drug therapy
Streptococcal Infections* / diagnosis
Streptococcal Infections* / drug therapy
Streptococcus pyogenes

Substances

Clindamycin
Immunoglobulins, Intravenous