eMedicine Specialties > Infectious Diseases > Bacterial Infections
Botulism: Treatment & Medication
Updated: Sep 23, 2008
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Treatment
Medical Care
- 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 hospital-acquired infections, especially pneumonia (particularly aspiration pneumonia), is necessary, as is precaution to prevent aspiration. Aggressive pulmonary toilet with clearance of secretions, ventilatory support, and incentive spirometry are typically used.
- 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.
- Careful attention to peripheral and central intravenous catheters with regular site rotation to reduce the risks of thrombophlebitis, cellulitis, and line infections should be part of the supportive care.
- Deep venous thrombosis (DVT) prophylaxis is also a standard component of intensive care management.
Surgical Care
Wound botulism requires incision and thorough debridement of the infected wound, antitoxin therapy, and high-dose intravenous penicillin therapy.
Consultations
- 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.
Diet
- 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.
Activity
- Bedrest is initially required.
- Increase activity as tolerated.
Medication
Antibiotics are useful in wound botulism, but they have no role in foodborne botulism.
Antibiotics
When botulism develops following a wound infection, antibiotic therapy and meticulous debridement of the wound are essential.
Penicillin G (Pfizerpen)
Preferred drug of choice for wound botulism. Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
20-30 million U/kg/d IV in 6 divided doses
Pediatric
Not established
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Chloramphenicol (Chloromycetin)
Alternate to penicillin. Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.
Adult
50 mg/kg/d IV
Pediatric
Not established
Upon concurrent administration with barbiturates, chloramphenicol serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while on therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome)
Clindamycin (Cleocin)
Alternative to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
600 mg IV q8h
Pediatric
Not established
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis
Antitoxins
These agents are essential in the treatment of foodborne botulism and wound botulism. Trivalent A-B-E antitoxin is available at the Centers for Disease Control and Prevention (CDC). The CDC phone numbers are 404-639-3670 or 639-2888 or 639-3753. Polyvalent antitoxin for toxins A, B, C, D, E, and F is also available for specific outbreaks. Because only equine antitoxin is available, all patients must be tested for hypersensitivity to equine serum. Twenty percent of patients experience some degree of serum sickness or hypersensitivity reaction, and anaphylaxis can also occur. Patients who react to a test dose must be desensitized. Because of the risk of adverse reactions, prophylactic antitoxin is not recommended in patients who are exposed to botulism toxin but who have no symptoms. These patients may undergo gastric lavage or induced vomiting in an attempt to eliminate the toxin prior to absorption.
Trivalent A-B-E antitoxin
Administer as soon as possible in patients who are symptomatic with high clinical suspicion of foodborne botulism and wound botulism.
An antitoxin may be beneficial, even when provided several weeks after toxin ingestion because circulating toxin has been detected in serum as long as 30 d later.
Antitoxin will not neutralize toxin already bound to neuromuscular junctions. Although antitoxin can slow disease progression, it has no effect on established neurologic deficits.
Adult
1 vial IV and 1 vial IM for foodborne botulism and wound botulism; repeat IV in 2-4 h if symptoms persist
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Serum sickness or hypersensitivity reactions occur in 20% of antitoxin recipients
More on Botulism |
| Overview: Botulism |
| Differential Diagnoses & Workup: Botulism |
 Treatment & Medication: Botulism |
| Follow-up: Botulism |
| Multimedia: Botulism |
| References |
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Further Reading
Keywords
botulism, human botulism, Clostridium botulinum, C botulinum, foodborne botulism, food-borne botulism, wound botulism, infant botulism, infantile botulism, CB toxin, botulinum toxin, FBB, WB, food poisoning
