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Intravenous immunoglobulin treatment in patients with streptococcal toxic shock syndrome in southern Sweden – A retrospective population-based study

Wullt, Olof ; Utbult, Charlotta ; Carlson, Erik ; Ljungquist, Oskar LU ; Sunnerhagen, Torgny LU orcid ; Bläckberg, Anna LU and Torisson, Gustav LU orcid (2026) In Open Forum Infectious Diseases 13(3). p.1-7
Abstract
Background
Intravenous immunoglobulins (IVIG) have been suggested as an adjunctive treatment in streptococcal toxic shock syndrome (STSS), but there are no conclusive trials. In southern Sweden, IVIG is routinely used in certain hospitals but not in others. We hypothesized that this would resemble a natural experiment, and aimed to evaluate the effect of IVIG in STSS patients.

Method
We conducted a population-based retrospective cohort study on STSS cases in southern Sweden from 2017 to 2024. The main exposure was any IVIG treatment, and the primary outcome was 30-day mortality. Cox regression, adjusted for lactate, Sequential Organ Failure Assessment score, Charlson Comorbidity Index and concurrent clindamycin treatment,... (More)
Background
Intravenous immunoglobulins (IVIG) have been suggested as an adjunctive treatment in streptococcal toxic shock syndrome (STSS), but there are no conclusive trials. In southern Sweden, IVIG is routinely used in certain hospitals but not in others. We hypothesized that this would resemble a natural experiment, and aimed to evaluate the effect of IVIG in STSS patients.

Method
We conducted a population-based retrospective cohort study on STSS cases in southern Sweden from 2017 to 2024. The main exposure was any IVIG treatment, and the primary outcome was 30-day mortality. Cox regression, adjusted for lactate, Sequential Organ Failure Assessment score, Charlson Comorbidity Index and concurrent clindamycin treatment, were used. We modelled IVIG as a time-dependent variable to address immortal time bias.

Results
In total, 106 patients fulfilled STSS criteria, of which 56 (53%) were treated with IVIG. Despite geographical differences, the IVIG group was younger, had fewer comorbidities but higher disease severity at baseline. Crude analysis suggested a lower mortality in the IVIG group (Hazard ratio 0.69, 95% CI: 0.34–1.41). However, after adjusting for covariates and accounting for immortal time bias, the hazard ratio was estimated at 1.69 (95% CI: 0.66–4.30).

Conclusion
Although our study included a large population of STSS patients, our results were inconclusive regarding the effect of IVIG on 30-day mortality. This study highlights the risk of bias in observational studies in rare conditions. Prospective interventional studies are needed to determine the efficacy of IVIG in patients with STSS. (Less)
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author
; ; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
Open Forum Infectious Diseases
volume
13
issue
3
article number
ofag092
pages
1 - 7
publisher
Oxford University Press
ISSN
2328-8957
DOI
10.1093/ofid/ofag092
language
English
LU publication?
yes
id
46811e1f-9d58-4ba8-8818-6ab205b5e238
date added to LUP
2026-02-28 21:40:05
date last changed
2026-03-18 07:42:12
@article{46811e1f-9d58-4ba8-8818-6ab205b5e238,
  abstract     = {{Background<br/>Intravenous immunoglobulins (IVIG) have been suggested as an adjunctive treatment in streptococcal toxic shock syndrome (STSS), but there are no conclusive trials. In southern Sweden, IVIG is routinely used in certain hospitals but not in others. We hypothesized that this would resemble a natural experiment, and aimed to evaluate the effect of IVIG in STSS patients.<br/><br/>Method<br/>We conducted a population-based retrospective cohort study on STSS cases in southern Sweden from 2017 to 2024. The main exposure was any IVIG treatment, and the primary outcome was 30-day mortality. Cox regression, adjusted for lactate, Sequential Organ Failure Assessment score, Charlson Comorbidity Index and concurrent clindamycin treatment, were used. We modelled IVIG as a time-dependent variable to address immortal time bias.<br/><br/>Results<br/>In total, 106 patients fulfilled STSS criteria, of which 56 (53%) were treated with IVIG. Despite geographical differences, the IVIG group was younger, had fewer comorbidities but higher disease severity at baseline. Crude analysis suggested a lower mortality in the IVIG group (Hazard ratio 0.69, 95% CI: 0.34–1.41). However, after adjusting for covariates and accounting for immortal time bias, the hazard ratio was estimated at 1.69 (95% CI: 0.66–4.30).<br/><br/>Conclusion<br/>Although our study included a large population of STSS patients, our results were inconclusive regarding the effect of IVIG on 30-day mortality. This study highlights the risk of bias in observational studies in rare conditions. Prospective interventional studies are needed to determine the efficacy of IVIG in patients with STSS.}},
  author       = {{Wullt, Olof and Utbult, Charlotta and Carlson, Erik and Ljungquist, Oskar and Sunnerhagen, Torgny and Bläckberg, Anna and Torisson, Gustav}},
  issn         = {{2328-8957}},
  language     = {{eng}},
  number       = {{3}},
  pages        = {{1--7}},
  publisher    = {{Oxford University Press}},
  series       = {{Open Forum Infectious Diseases}},
  title        = {{Intravenous immunoglobulin treatment in patients with streptococcal toxic shock syndrome in southern Sweden – A retrospective population-based study}},
  url          = {{https://lup.lub.lu.se/search/files/245169156/ofag092.pdf}},
  doi          = {{10.1093/ofid/ofag092}},
  volume       = {{13}},
  year         = {{2026}},
}