Medical Care
In patients with botulism, supportive care, especially ventilatory support, is essential. [35]
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Promptly initiate ventilatory support, because respiratory muscle weakness rapidly progresses and the gag reflex is frequently impaired, which predisposes patients to respiratory failure and/or aspiration. Patients need continued suctioning and may require intubation or tracheostomy.
Antitoxin (see Medication) dramatically alters the course of the disease, especially if administered within the first 24 hours.
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As of 2010, Heptavalent antitoxin active against all 7 types of botulism toxin (A-G) has been available from the CDC for treatment for food borne and wound botulism. It is very effective and safe, and should be started as soon as possible, as longer periods of ventilation were needed if the antitoxin was started more than 12 hours after hospitalization. [15]
A joint task force that analyzed the allergy risk of botulinum antitoxin treatment reported that anaphylaxis incidence was low at 1.64% (5/305 patients) for HBAT and 1.16% (8/687 patients) for all other botulinum antitoxins (relative risk, 1.41 [95% confidence interval, .47-4.27]; P = .5). [36]
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Human Botulism Immune Globulin Intravenous (BabyBIG) should be administered for infant botulism. It is effective if given within 7 days of onset of symptoms. It can only be obtained from the California Department of Public Health by calling the Infant Botulism Treatment and Prevention Program (IBTPP) (Telephone #510-231-7600). It is given as an IV drip of 50 mg/kg over 1 hour and has to be reconstituted 2 hours before use in 5% sucrose and 1% albumin solutions. It is very safe and not associated with the anaphylactic reactions that were previously seen with antitoxins derived from horse serum. Without treatment with BabyBIG, infants have prolonged symptoms and an increased number of complications, including longer hospitalizations, longer ICU stays and higher overall costs. Although the cost of BabyBig is $45,300 per infant, this cost is more than made up by decreased hospital costs when BabyBIG is used. [12] Although one study showed an increase in hospital charges for infants that received treatment with BabyBIG, even in that study there was a decrease in morbidity, the number of days spent on a ventilator and length of hospital stay. [37] In a comprehensive review of infant botulism, the authors found that treatment with BabyBig decreased both morbidity and hospital costs, and the high cost of BabyBIG was justified by these results. The authors strongly felt that both supportive therapy and the use of BabyBIG should be initiated as early as possible based on clinical findings, and not wait for laboratory confirmation. [37]
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In general, antibiotic therapy to clear clostridial GI infection in infant botulism is contraindicated, because the treatment increases toxin release and worsens the condition. Antibiotics may be used to treat secondary bacterial infections, but if possible this should be done after BabyBIG has been given. [13]
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Aminoglycosides, such as gentamicin or tobramycin, may potentiate the neuromuscular blockade caused by the botulinum toxin, and therefore are contraindicated. It is recommended that aminoglycosides not be administered for the next 6 months. [13]
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Many experts recommend antibiotic therapy after antitoxin administration in wound botulism. Penicillin G and Metronidazole are most commonly used, but Clindamycin has also been shown to be effective. Aminoglycosides, Nalidixic acid and Trimethoprim-sulfamethoxazole have not been shown to be effective against C. botulinum, and should not be used. [15]
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Cathartics containing Magnesium should not be used. [15]
Surgical Care
In patients with wound botulism, surgical debridement of the wound is indicated to remove the source of toxin production.
Consultations
Consultations with an infectious diseases specialist and a neurologist are frequently beneficial.
Consultations with the local public health and state health departments are very useful, and will often facilitate obtaining antitoxin and getting confirmatory testing done. Also, the CDC may be called directly at 770-488-7100 to obtain management advice and antitoxin. For management advice for infant botulism and for obtaining BabyBig, the IBTPP should be called at 501-231-7600.
Diet
Tube feeding may be useful if GI tract motility is intact. If motility is not intact, consider parenteral feeding.
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This is a photomicrograph of Clostridium botulinum stained with Gentian violet. The bacterium, C botulinum, produces a neurotoxin which causes the rare, but serious, paralytic illness, botulism.
