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Botulism Treatment & Management

  • Author: Kirk M Chan-Tack, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
Updated: Mar 23, 2015

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.



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.

Contributor Information and Disclosures

Kirk M Chan-Tack, MD Medical Officer, Division of Antiviral Products, Center for Drug Evaluation and Research, Food and Drug Administration

Disclosure: Nothing to disclose.


John Bartlett, MD Professor Emeritus, Johns Hopkins University School of Medicine

John Bartlett, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Clinical Pharmacology, American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, American Thoracic Society, American Venereal Disease Association, Association of American Physicians, Infectious Diseases Society of America, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Pranatharthi Haran Chandrasekar, MBBS, MD Professor, Chief of Infectious Disease, Program Director of Infectious Disease Fellowship, Department of Internal Medicine, Wayne State University School of Medicine

Pranatharthi Haran Chandrasekar, MBBS, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, International Immunocompromised Host Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

David Hall Shepp, MD Program Director, Fellowship in Infectious Diseases, Department of Medicine, North Shore University Hospital; Associate Professor, New York University School of Medicine

David Hall Shepp, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Received salary from Gilead Sciences for management position.

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