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CBRNE - Botulism: Treatment & Medication

Author: Peter P Taillac, MD, Associate Clinical Professor of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center
Coauthor(s): Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Contributor Information and Disclosures

Updated: Apr 10, 2008

Treatment

Emergency Department Care

Antitoxin should be administered as soon as the clinical diagnosis is established, as laboratory confirmation requires days. The early administration of antitoxin will not reverse the course of the intoxication but will prevent further progression of paralysis. This is the best method to prevent diaphragmatic involvement and the need for mechanical ventilation. Antitoxin can only bind neurotoxin free in the blood. Once in the neuron, it cannot be bound.

• Food-borne botulism
  • Monitor asymptomatic individuals who have eaten food suspected of being contaminated for the appearance of neurologic signs and symptoms.
  • Enemas and cathartics or whole-bowel irrigation may be used (if no ileus is present) to purge the gut of toxin. If ingestion occurred within the past few hours, emetics or gastric lavage may aid in the removal of toxin.
• Infant botulism: Most cases progress to complete respiratory failure. Intubation is required for a median of 16-23 days. Tracheostomy usually is not required.
• Wound botulism
  • Wound botulism requires thorough debridement of the wound site, even if it appears to be healing well.
  • Follow this by injection of 3% hydrogen peroxide to produce aerobic conditions. Hydrogen peroxide itself is not innocuous to tissues, and some have advocated using hyperbaric oxygen therapy if available.
  • Antitoxin may be injected directly into the wound site.
  • Urinary retention may require use of a catheter.
• Respiratory concerns
  • In adults, botulism results in pulmonary complications in 81% of patients, with ventilatory failure in one third.
  • Monitor spirometry, pulse oximetry, and arterial blood gas measurements, with particular attention placed on serial measurements of maximal static inspiratory pressure and respiratory vital capacity to help in predicting respiratory failure.
  • Strongly consider intubation and mechanical ventilation when vital capacity is less than 30% of predicted (or <12 mL/kg), particularly when absolute or relative hypercarbia and rapidly progressive paralysis with hypoxemia are evident.

Consultations

• Medical care providers who suspect botulism in a patient should immediately call their state health department's emergency 24-hour telephone number. The state health department will contact the CDC to report suspected botulism cases, arrange for a clinical consultation by telephone and, if indicated, request release of botulinum antitoxin. State health departments should call the CDC 24-hour telephone number at 770-488-7100. The call will be taken by the CDC Emergency Operations Center, which will page the Foodborne and Diarrheal Diseases Branch medical officer on call.
• Pulmonology for respiratory sequelae
• Surgery for wound care
• Infectious disease specialist for management issues

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications. Medication commonly used in the treatment of botulism is described below. In addition to that described, guanethidine and 4-aminopyridine have been used for the treatment of botulinum paralysis but have not been shown to be effective.

The use of local antibiotics such as penicillin G or metronidazole may be helpful in eradicating C botulinum in wound botulism. Antibiotic use is not recommended for infant botulism because cell death and lysis may result in the release of more toxin. Aminoglycoside antibiotics and tetracyclines, in particular, may increase the degree of neuromuscular blockade by impairing neuronal calcium entry.

Antitoxin therapy

Therapy consists of approximately 10,000 IU of antibodies against toxin types A, B, and E to neutralize serum toxin concentrations.

Trivalent equine botulism antitoxin

CDC recommends administration of 1 vial of antitoxin for adult patients with botulism as soon as diagnosis is made, without waiting for laboratory confirmation; before administration of antitoxin, consider skin testing for sensitivity to serum or antitoxin (see Contraindications, below).
1 vial of trivalent botulism antitoxin administered IV results in serum levels of type A, B, and E antibodies capable of neutralizing serum toxin concentrations in substantial excess of those reported for botulism patients; administration of 1 vial of antitoxin IV recommended and need not be repeated (circulating antitoxins have a half-life of 5-8 d).
Antitoxin packages, which include instructions for skin or conjunctival testing for hypersensitivity to horse serum and a regimen for desensitization, are available through the CDC (emergency assistance number 770-488-7100); Antitoxin packages also may be obtained through state health departments.
Antitoxin neutralizes toxin not yet bound to nerve terminals and has circulating half-life of 5-8 d; patients who do not receive antitoxin treatment show free toxin in serum for up to 28 d.

Immune Globulin

Botulism immune globulin, human

For infant botulism, IV Human Botulinum Immune Globulin (BIG-IV or BabyBIG) trials in California were completed in early 1997; trials demonstrated safety and efficacy of human-derived botulinum immune globulin and a reduced mean hospital stay from 5.5 wk to 2.5 wk.
BIG-IV is now FDA approved and is only available from the California Department of Health Services (24-h telephone: 510-540-2646).
Solvent-detergent treated and viral screened immune globulin. Derived from pooled adult plasma from persons immunized with botulinum toxoid that developed high neutralizing antibody titers against botulinum neurotoxins type A and B. Indicated to treat infant botulism (age <1 y) caused by type A or B C botulinum.

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