Botulism Treatment & Management

Updated: Feb 15, 2019
  • Author: Kirk M Chan-Tack, MD; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Medical Care

On March 22, 2013, the FDA approved the first botulism antitoxin that can neutralize all 7 known botulinum nerve toxin serotypes. The heptavalent antitoxin is derived from horse plasma and is the only drug available for treating botulism in patients older than 1 year, including adults. It is also the only available drug for treating infant botulism that is not caused by nerve toxin type A or B. [12, 13, 14, 15]

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.