Botulism Treatment & Management
- Author: Kirk M Chan-Tack, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD more...
Rigorous and supportive care is essential in patients with botulism.
Meticulous airway management is paramount, as respiratory failure is the most important threat to survival in patients with botulism.
Patients with symptoms of botulism or known exposure should be hospitalized and closely observed.
Spirometry, pulse oximetry, vital capacity, and arterial blood gases should be evaluated sequentially.
Respiratory failure can occur with unexpected rapidity.
Intubation and mechanical ventilation should be strongly considered when the vital capacity is less than 30% of predicted, especially when paralysis is progressing rapidly and hypoxemia with hypercarbia is present.
Many patients require intubation and ventilatory support for a few days to months.
Tracheostomy may prove necessary to manage secretions.
Patients with bowel sounds are administered cathartics and enemas to remove unabsorbed botulinum toxin from the intestine.
Magnesium salts, citrate, and sulfate should not be administered because magnesium can potentiate the toxin-induced neuromuscular blockade.
Stress ulcer prophylaxis is also a standard component of intensive care management.
If an ileus is present, nasogastric suction and intravenous hyperalimentation are very helpful supportive measures. If no ileus is present, tube feeding can be used for nutritional supplementation.
A Foley catheter is often used to treat bladder incontinence. This must be monitored conscientiously and changed regularly.
Measures to reduce the risk of nosocomial infections include the following:
Close observation for urinary tract infection is essential. Foley catheters should be changed on a regular basis.
Meticulous skin care is required to prevent decubital ulcers and skin breakdown.
Deep venous thrombosis (DVT) prophylaxis is also a standard component of intensive care management.
Wound botulism requires incision and thorough debridement of the infected wound, antitoxin therapy, and high-dose intravenous penicillin therapy.
A nutritionist should be consulted for hyperalimentation and tube-feeding recommendations and monitoring.
Physical and occupational therapists are needed to work on range-of-motion exercises and assisted ambulation, as tolerated.
A psychiatrist and/or a psychologist is recommended for counseling, as needed; patients with prolonged hospitalization, slow recovery, and complications from the disease or from extended hospitalization are at increased risk for depression.
Pastoral care is recommended, as needed.
Physical medicine and rehabilitation specialists may be helpful in coordinating long-term rehabilitation planning once sustained recovery has begun.
Nasogastric suction and intravenous hyperalimentation are important when an ileus is present. If no ileus is present or when the ileus resolves, tube feeding can be used for nutritional supplementation.
Oral intake should be reinstituted gradually under the following conditions:
Respiratory status is stable without mechanical ventilation.
Swallowing safety has been assessed and confirmed with a swallowing study, as appropriate.
Ileus has resolved.
Bedrest is initially required.
Increase activity as tolerated.
Lowes R. FDA Approves First Heptavalent Botulism Antitoxin. Medscape Medical News. Mar 25 2013. Available at http://www.medscape.com/viewarticle/781389. Accessed: April 3 2013.
US Food and Drug Administration. FDA Approves First Botulism Antitoxin for Use in Neutralizing All Seven Known Botulinum Nerve Toxin Serotypes. FDA. Mar 22 2013. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm345128.htm. Accessed: April 3 2013.
Hill SE, Iqbal R, Cadiz CL, Le J. Foodborne botulism treated with heptavalent botulism antitoxin. Ann Pharmacother. 2013 Feb. 47(2):e12. [Medline].
Webb RP, Smith LA. What next for botulism vaccine development?. Expert Rev Vaccines. 2013 May. 12(5):481-92. [Medline].
[Guideline] Bossi P, Tegnell A, Baka A, et al. Bichat guidelines for the clinical management of botulism and bioterrorism-related botulism. Euro Surveill. 2004 Dec 15. 9(12):E13-4. [Medline].
Passaro DJ, Werner SB, McGee J, et al. Wound botulism associated with black tar heroin among injecting drug users. JAMA. 1998 Mar 18. 279(11):859-63. [Medline].
Shaffer N, Wainwright RB, Middaugh JP, et al. Botulism among Alaska Natives. The role of changing food preparation and consumption practices. West J Med. 1990 Oct. 153(4):390-3. [Medline].
Yuan J, Inami G, Mohle-Boetani J, Vugia DJ. Recurrent wound botulism among injection drug users in California. Clin Infect Dis. 2011 Apr 1. 52(7):862-6. [Medline].
Angulo FJ, Getz J, Taylor JP, et al. A large outbreak of botulism: the hazardous baked potato. J Infect Dis. 1998 Jul. 178(1):172-7. [Medline].
St Louis ME, Peck SH, Bowering D, et al. Botulism from chopped garlic: delayed recognition of a major outbreak. Ann Intern Med. 1988 Mar. 108(3):363-8. [Medline].
Arnon SS. Creation and development of the public service orphan drug Human Botulism Immune Globulin. Pediatrics. 2007 Apr. 119(4):785-9. [Medline].
Cai S, Singh BR, Sharma S. Botulism diagnostics: from clinical symptoms to in vitro assays. Crit Rev Microbiol. 2007 Apr-Jun. 33(2):109-25. [Medline].
Cardoso F, Jankovic J. Clinical use of botulinum neurotoxins. Curr Top Microbiol Immunol. 1995. 195:123-41. [Medline].
Cherington M. Botulism: update and review. Semin Neurol. 2004 Jun. 24(2):155-63. [Medline].
Clemmens MR, Bell L. Infant botulism presenting with poor feeding and lethargy: a review of 4 cases. Pediatr Emerg Care. 2007 Jul. 23(7):492-4. [Medline].
Critchley EM, Mitchell JD. Human botulism. Br J Hosp Med. 1990 Apr. 43(4):290-2. [Medline].
Fox CK, Keet CA, Strober JB. Recent advances in infant botulism. Pediatr Neurol. 2005 Mar. 32(3):149-54. [Medline].
Glik D, Harrison K, Davoudi M, et al. Public perceptions and risk communications for botulism. Biosecur Bioterror. 2004. 2(3):216-23. [Medline].
Hallett M. One man's poison--clinical applications of botulinum toxin. N Engl J Med. 1999 Jul 8. 341(2):118-20. [Medline].
Hatheway CL. Botulism: the present status of the disease. Curr Top Microbiol Immunol. 1995. 195:55-75. [Medline].
Jahn R, Niemann H. Molecular mechanisms of clostridial neurotoxins. Ann N Y Acad Sci. 1994 Sep 15. 733:245-55. [Medline].
Lawrence DT, Dobmeier SG, Bechtel LK, et al. Food poisoning. Emerg Med Clin North Am. 2007 May. 25(2):357-73; abstract ix. [Medline].
Lecour H, Ramos H, Almeida B, et al. Food-borne botulism. A review of 13 outbreaks. Arch Intern Med. 1988 Mar. 148(3):578-80. [Medline].
Long SS. Infant botulism and treatment with BIG-IV (BabyBIG). Pediatr Infect Dis J. 2007 Mar. 26(3):261-2. [Medline].
Oguma K, Fujinaga Y, Inoue K. Structure and function of Clostridium botulinum toxins. Microbiol Immunol. 1995. 39(3):161-8. [Medline].
Roblot P, Roblot F, Fauchere JL, et al. Retrospective study of 108 cases of botulism in Poitiers, France. J Med Microbiol. 1994 Jun. 40(6):379-84. [Medline].
Schiavo G, Rossetto O, Tonello F, et al. Intracellular targets and metalloprotease activity of tetanus and botulism neurotoxins. Curr Top Microbiol Immunol. 1995. 195:257-74. [Medline].
Shapiro RL, Hatheway C, Swerdlow DL. Botulism in the United States: a clinical and epidemiologic review. Ann Intern Med. 1998 Aug 1. 129(3):221-8. [Medline].
Slater PE, Addiss DG, Cohen A, et al. Foodborne botulism: an international outbreak. Int J Epidemiol. 1989 Sep. 18(3):693-6. [Medline].
Sobel J, Tucker N, Sulka A, et al. Foodborne botulism in the United States, 1990-2000. Emerg Infect Dis. 2004 Sep. 10(9):1606-11. [Medline].
Varma JK, Katsitadze G, Moiscrafishvili M, et al. Signs and symptoms predictive of death in patients with foodborne botulism--Republic of Georgia, 1980-2002. Clin Infect Dis. 2004 Aug 1. 39(3):357-62. [Medline].
Weber JT, Goodpasture HC, Alexander H, et al. Wound botulism in a patient with a tooth abscess: case report and review. Clin Infect Dis. 1993 May. 16(5):635-9. [Medline].
Wilcox PG, Morrison NJ, Pardy RL. Recovery of the ventilatory and upper airway muscles and exercise performance after type A botulism. Chest. 1990 Sep. 98(3):620-6. [Medline].