In vitro amplification of toxic shock syndrome toxin-1 by intravaginal devices

Device-Associated Menstrual Toxic Shock Syndrome

In the 1980s, menstrual toxic shock syndrome (mTSS) became a household topic, particularly among mothers and their daughters. The research performed at the time, and for the first time, exposed the American public as well as the biomedical community, in a major way, to understanding disease progression and investigation. Those studies led to the identification of the cause, Staphylococcus aureus and the pyrogenic toxin superantigen TSS toxin 1 (TSST-1), and many of the risk factors, for example, tampon use. Those studies in turn led to TSS warning labels on the outside and inside of tampon boxes and, as important, uniform standards worldwide of tampon absorbency labeling. This review addresses our understanding of the development and conclusions related to mTSS and risk factors. We leave the final message that even though mTSS is not commonly in the news today, cases continue to occur. Additionally, S. aureus strains cycle in human populations in roughly 10-year intervals, possibly dependent on immune status. TSST-1-producing S. aureus bacteria appear to be reemerging, suggesting that physician awareness of this emergence and mTSS history should be heightened.

Effect of non-absorbent intravaginal menstrual/contraceptive products on Staphylococcus aureus and production of the superantigen TSST-1

Tampons are associated with toxic shock syndrome (mTSS). One reason for this association is oxygen introduction within tampons into the anaerobic vagina. Oxygen is required for Staphylococcus aureus to produce TSS toxin-1 (TSST-1). There have been changes in use of medical devices to control menstrual flow, including increased use of menstrual discs and cups. These devices composed of solid, flexible materials do not absorb menstrual fluid and thus do not trap oxygen. This study evaluates tampons and non-absorbent devices for effect on S. aureus and TSST-1 production. There are three in vitro tests to evaluate devices for effect on TSST-1 production: (1) stationary flask, (2) shake flask, and (3) tampon sac. In this study, 100% rayon and 100% cotton tampons with three absorbencies, contraceptive diaphragms, and menstrual discs and cups were tested for effect on S. aureus growth and TSST-1 production. Product composition did not affect bacterial growth or TSST-1 production. Tampons showed no effect on S. aureus growth compared with no-tampon controls, but tampons showed enhanced TSST-1 production as a function of trapped oxygen in stationary cultures and tampon sacs but not in shake flasks. The non-absorbent devices showed no enhanced S. aureus growth or TSST-1 production compared with no-device controls. These studies are consistent with the association of tampons with mTSS as a function of absorbency, but they suggest the occasional association of mTSS with non-absorbent devices may be coincidental as opposed to co-causative.

Menstrual toxic shock syndrome: case report and systematic review of the literature

Menstrual toxic shock syndrome (mTSS) is a life-threatening disease caused by superantigen-producing Staphylococcus aureus. Incidence ranges from 0·03 to 0·50 cases per 100 000 people, with overall mortality around 8%. In this Grand Round, we present the case of a previously healthy 23-year-old menstruating woman who was diagnosed with mTSS after she presented at our hospital with a septic condition for the second time. The diagnosis was confirmed by fulfilment of the clinical criteria outlined by the US Centers for Disease Control and Prevention (CDC; fever, rash, desquamation, hypotension, and multi-system involvement) as well as a nasal swab positive for the S aureus strain and presence of the gene encoding for toxic shock syndrome toxin 1 (TSST-1). In the early 1980s, when mTSS was first described, use of tampons was considered the main risk factor. Today, the complex interplay between pathogenic factors of S aureus, immunological mechanisms of the host, and changes in the vaginal ecosystem during menstruation has broadened current understanding of the disease, and the CDC criteria have appreciable limitations in everyday clinical practice.

Propensity of tampons and barrier contraceptives to amplify Staphylococcus aureusToxic shock syndrome toxin-I

Objective: Although the incidence of reported cases of toxic shock syndrome (TSS) has declined in recent years, the disease continues to occur in menstruating women using the newer, less-absorbent tampons or barrier contraceptives. Extant tampons and other vaginal devices were tested for the ability to induce TSS toxin-1 (TSST-1) by a TSS strain of Staphylococcus aureus MN8, a known high-toxin producer. Tested for the first time were 20 varieties of tampons, including 2 all-cotton brands newly introduced in the United States, a polyurethane contraceptive sponge, a latex diaphragm, and a polymer menstrual collection cup.

Methods: All products were washed in sterile distilled water prior to use to reduce the effect of leachable chemicals. Duplicate experiments with unwashed products were also performed. Entire tampons and other test products were immersed in brain heart infusion broth plus yeast extract (BHIY) and inoculated with S. aureus MN8, a known TSST-1 producer. After incubation, the culture supernatants were assayed for TSST-1 by gel immunodiffusion.

Results: Except for all-cotton tampons, greater amounts of TSST-1 were detected in the supernatant fluid of washed tampons than detected in those which were not washed. While TSST-1 levels in unwashed non-cotton tampons ranged from 0.5 to 8 μg/ml, when these products were washed, TSST-1 levels increased to 2–32 μg/ml. In all-cotton tampons, whether washed or not, there was no detectable TSST-1.

Conclusions: The propensity for all-cotton tampons not to amplify TSST-1 in vitro suggests they would lower the risk for tampon-associated TSS.

Zinc and the immune system

Zn is an essential trace element for all organisms. In human subjects body growth and development is strictly dependent on Zn. The nervous, reproductive and immune systems are particularly influenced by Zn deficiency, as well as by increased levels of Zn. The relationship between Zn and the immune system is complex, since there are four different types of influence associated with Zn. (1) The dietary intake and the resorption of Zn depends on the composition of the diet and also on age and disease status. (2) Zn is a cofactor in more than 300 enzymes influencing various organ functions having a secondary effect on the immune system. (3) Direct effects of Zn on the production, maturation and function of leucocytes. (4) Zn influences the function of immunostimulants used in the experimental systems. Here we summarize all four types of influence on the immune function. Nutritional aspects of Zn, the physiology of Zn, the influence of Zn on enzymes and cellular functions, direct effects of Zn on leucocytes at the cellular and molecular level, Zn-altered function of immunostimulants and the therapeutic use of Zn will be discussed in detail.

Influence of lactobacilli on the adhesion of Staphylococcus aureus and Candida albicans to fibers and epithelial cells

The ability of organisms to adhere to and form biofilms on fibrous materials is believed to be an important initiating step in the induction of several diseases, such as toxic shock syndrome. Using an in vitro assay, a moderately hydrophobic strain of Staphylococcus aureus (water contact angle 35 degrees) and a hydrophilic Candida albicans (shown by a hexadecane test) were highly adherent to commercial diaper fibers. The lumen side of the diaper was porous and the fibers were very hydrophobic (> 140 degrees), but the internal section was very hydrophilic (0 degrees), presumably for lus strains was present. Surfaces precoated with lactobacilli inhibited staphylococcal adhesion by 26-97%, and candida by 0-67%. When the lactobacilli were used to challenge adherent pathogens, there was 99% displacement of the S. aureus and up to 91% displacement of C. albicans. Hydrophobic L. acidophilus 76 (54 degrees) and T-13 (80 degrees) were the most effective of five Lactobacillus isolates tested at interference by precoating. The moderately hydrophilic L. casei var rhamnosus GR-1 (33 degrees) was the most effective at displacing the yeast. Experiments with uroepithelial cells also showed that the lactobacilli could significantly interfere with the adhesion of both pathogens to the cells. The results demonstrate the rapidity with which two pathogens adhered to fibers and epithelial cells, and raised the possibility that members of the normal female urogenital flora might interfere with infections caused by these organisms.

Investigation by improved syringe method of effect of tampons on production in vitro of toxic shock syndrome toxin 1 by Staphylococcus aureus

Twenty-seven types of commercial tampons from five manufacturers were tested in a sealed-syringe method to determine their effect on the growth of Staphylococcus aureus and the production of toxic shock syndrome toxin 1. In this improvement of the syringe method, the available air is limited to that which is contained within the sealed syringe containing the tampon. The culture medium was buffered, and blood and CO2 were included in the incubation to better simulate the vaginal environment during menstruation. Variables of tampon weight, composition, air volume, and absorbency were examined for their effect on the production of toxic shock syndrome toxin 1. Generally, with the exception of brand E, toxin production in the presence of tampons was equal to or lower than that in a sealed control syringe containing air but no tampon.

Effects of blood and different media on the production of toxic shock syndrome toxin 1 by Staphylococcus aureus in the tampon sac method

The use of three different agar concentrations in the tampon sac method resulted in slightly higher fluid uptake by the tampons when a 0.5% agar concentration was used. However, there was essentially no difference in the total amount of toxin produced. The largest amount of toxic shock syndrome toxin 1 was produced with brain heart infusion agar, followed closely by 3% NZ-amine NAK-1% yeast extract medium. The addition of plasma and serum to the inoculum resulted in increases (62 and 73%, respectively) in toxin production. The addition of whole blood to the inoculum had a variable effect on toxin production, with an increase in the amount of toxin produced with some tampons and not with others. Over fivefold differences in the amount of toxin produced were obtained when duplicate experiments were done on successive days, whereas the differences were less than twofold for experiments done on the same day. This was related to the effect of small changes in the parameters on toxic shock syndrome toxin 1 production.

Toxic shock syndrome

In the past 10 years, we have learned much about TSS and S. aureus and its toxins. A number of important biologic principles have been reemphasized in this first decade of TSS research: S. aureus is a very complex organism, one not likely to yield quick answers; in vitro observations must always be confirmed in the patient; animal models may not always be reliable replicates of human disease; and epidemiologic associations cannot be equated with causation. Toxic shock is an intricate phenomenon with many interesting scientific facets. Unraveling its mysteries will undoubtedly teach us more about the complex interaction of patients and microorganisms.

Production of toxic shock syndrome toxin 1 by Staphylococcus aureus restricted to endogenous air in tampons

All types of four brands of tampons were tested in triplicate by a tampon sac method for their effect on production of toxic shock syndrome toxin 1 (TSST-1). In this method the available air is limited to that which is in the tampon sac. Tampons were weighed and inserted into dialysis sacs inoculated with a TSST-1-producing Staphylococcus aureus strain; the sacs were submerged into brain heart infusion agar, which was allowed to harden around the sacs, and were incubated for 18 h at 37 degrees C. The tampons were removed, weighed, and extracted; the CFU of staphylococci and the amount of toxin present in the extracts were determined. Glass wool was used in place of the tampons as one control, and inoculated empty sacs were used as a second control. The total CFU were consistently greater than 2 X 10(11) for the tampons and glass wool and less than or equal to 10(11) for the empty sac control. Total toxin production for all tampons tested and the glass wool was 2 to 10 times higher than the toxin produced with the empty sac control. These results indicate that tampons provide increased surface area for the staphylococci to grow and adequate oxygen for toxin production. No significant inhibition of growth of the staphylococci or TSST-1 production by any of the tampons tested was noted.

Production of toxic shock syndrome toxin 1 by Staphylococcus aureus as determined by tampon disk-membrane-agar method

The influence of 17 commercially available tampons on production of toxic shock syndrome toxin 1 (TSST-1) by Staphylococcus aureus was investigated by using a tampon disk method. Filter membranes overlaying agar medium (with or without blood) in small petri dishes were spread inoculated with a TSST-1-producing strain of S. aureus. Disks cut from unrolled tampons were pressed and laid on the inoculated membranes; incubation was for 19 h at 37 degrees C with 5% CO2 in air. CFU on the membranes and in the disks were enumerated, and the presence of TSST-1 in the disks and in the agar layers was determined. Tampons made of different materials supported characteristic levels of cell growth and toxin production in the tampon. Colonization of the interface surface of the tampon disks was heavy. The number of CFU extracted from the tampon disks ranged from 5 X 10(10) to 82 X 10(10). There was little variation in the CFU recovered from the membranes ([1.9 +/- 0.4] X 10(11)). Sixty to 170 micrograms of TSST-1 was recoverable from the agar, with an additional 10 to 90 micrograms recoverable from tampon disks, depending on the type of tampon disk. The amount of toxin in the agar layer from the various tampon disks was relatively constant and indicated an important contribution of toxin from vaginal S. aureus cells not growing in the tampon. The main role of tampons in toxic shock syndrome may be that of providing a fibrous surface for heavy colonization and sufficient air for TSST-1 production.

Investigation by syringe method of effect of tampons on production in vitro of toxic shock syndrome toxin 1 by Staphylococcus aureus

A syringe method was designed to test the effect of tampons on the growth of three toxic shock syndrome-associated strains of Staphylococcus aureus and their in vitro production of toxic shock syndrome toxin 1 (TSST-1) under different conditions. Various amounts of TSST-1 were recovered from different tampons inoculated with these strains. Generally, the addition of 10% porcine blood to the growth medium, incubation in the presence of 5% CO2, or the combination of these two factors resulted in the stimulation of TSST-1 production.