Approach
Supportive care is the mainstay of botulism therapy. Patients with suspected or confirmed botulism should undergo serial vital capacity assessments in the intensive care unit. In addition, patients should be assessed for the adequacy of gag and cough reflexes, control of oropharyngeal secretions, oxygen saturation, and inspiratory force. Mechanical ventilation should be considered for any patient with upper airway compromise (due to pharyngeal muscle paralysis) or a decline in vital capacity.[44]
In the UK, Public Health England has provided online guidelines for the management of botulism. Public Health England: botulism Opens in new window
Swift administration of botulism antitoxin is essential in the management of botulism cases.[44] No specific dose recommendations can be made due to the variability of the properties: for example, strength of the available antitoxin in different countries. Therefore, the product particular supplied with the vial(s) must be consulted. In the UK, antitoxin is available from local designated centres (www.toxbase.org), otherwise accessed outside working hours by telephoning the duty doctor at Public Health England.[53] Detailed instructions on administration are provided with each dose.
In March 2010, the US Centers for Disease Control and Prevention (CDC) announced the availability of a new heptavalent (A-G) botulism antitoxin (HBAT). CDC: infectious disease laboratories - our formulary Opens in new window In 2013, the US Food and Drug Administration approved use of HBAT in patients with a documented or suspected exposure to botulinum toxin who develop symptoms of botulism. HBAT, available only through the CDC, replaces previously licensed botulism antitoxin AB and investigational botulism antitoxin E.[65] The potential for anaphylaxis, delayed allergic reactions (serum sickness), and lifelong sensitisation to equine proteins, in addition to short half-lives, limits the use of antitoxins derived from equine plasma (such as HBAT) in the infant (<1 year) population.[66]
For wound and food botulism equine antitoxin is available for treatment at specific UK centres, but it is not recommended for use in infants for the reasons described above. Infant botulism is more common in the US, where a human-derived botulism immunoglobulin (also known as BabyBIG™) has been available since 2003. The efficacy and safety was demonstrated in a 5-year randomised, double-blinded, placebo-controlled trial in 122 subjects.[66][67] Infant Botulism Treatment and Prevention Program Opens in new window Infant botulism has also been successfully treated with human-derived botulism immunoglobulin (obtained from the California Department of Public Health Infant Botulism Treatment and Prevention Program) in the UK.[68][69]
Foodborne botulism
Toxin types A, B, and E account for most cases of foodborne botulism. Adults and children 1 year of age or older should receive botulism antitoxin. Several types of botulism antitoxin are available, which may differ in presentation, composition, dosage, and administration. Different countries may have different types available. Infants <1 year of age should receive the intravenous botulism immunoglobulin (human), also known as BabyBIG™. Human-derived botulism immunoglobulin is preferred in the infant (<1 year) population because antitoxins derived from equine plasma (such as HBAT) have shorter half-lives, and have been associated with anaphylaxis, delayed allergic reactions (serum sickness), and lifelong sensitisation to equine proteins.[66]
Gastric lavage may be attempted in adults if the food exposure was relatively recent. In the absence of an ileus, enemas or cathartic agents may be used to eliminate unabsorbed toxin from the gastrointestinal tract. Gastric lavage and/or enemas are not recommended in infants.
Wound botulism
Adults and children ≥1 year of age should receive botulism antitoxin. Several types of botulism antitoxin are available, which may differ in presentation, composition, dosage, and administration. Different countries may have different types available. Infants <1 year should receive the intravenous botulism immunoglobulin (human), also known as BabyBIG™.
In addition to the antitoxin, patients with wound botulism should undergo careful debridement. Clostridium botulinum abscess formation may be treated with benzylpenicillin, or metronidazole in penicillin-allergic patients. Aminoglycosides should be avoided in cases of confirmed or suspected botulism as they have been shown to cause neuromuscular blockade, and may therefore potentiate the toxin’s effects.[70]
Iatrogenic botulism
Type A and B botulinum toxin preparations are currently licensed for therapeutic and cosmetic purposes. In cases of iatrogenic botulism, antitoxin containing types A, B, and E should be administered to adults and children ≥1 year of age. Although it is rare that children <1 year would require therapeutic injections of botulism, they should receive the intravenous botulism immunoglobulin (human), also known as BabyBIG™.
Inhalational botulism (biological attack)
Inhalational botulism is not a naturally occurring entity and should be considered a biological attack until proven otherwise. Clinical manifestations of inhalational botulism are nearly indistinguishable from the other forms of botulism. The occurrence of a large number of cases of acute flaccid paralysis with bulbar palsies or an unusual clustering of illnesses should raise suspicion for intentional release of botulinum toxin. In such instances, the local and national health department and hospital infection control department should be notified immediately. However, there are no specific reporting requirements in the US outside of the requirement to report any case of botulism.
In the event of intentional dissemination of botulinum toxin, passive immunisation with trivalent equine antitoxin is effective in reducing the severity of symptoms if administered early in the course of the infection as recommended by the European Medicines Agency/Committee for Proprietary Medicinal Products (EMEA/CPMP) guidance document on use of medicinal products for treatment and prophylaxis of biological agents that might be used as weapons of bioterrorism.[71] In the event of intentional dissemination of botulinum toxin in the US, heptavalent botulism antitoxin (HBAT) may be dispensed by the Department of Defense. Nonetheless, the use of botulism antitoxin as a means of post-exposure prophylaxis has not been shown to be effective. Current recommendations by the US Working Group on Civilian Biodefense state that asymptomatic people believed to be exposed to the intentional release of toxin should remain under close medical supervision. Botulism immunoglobulin (BabyBIG™) has not been tested in adults or children >1 year. However, in the event of a bioterrorist attack, the use of BabyBIG™ could be considered a secondary option for the treatment of inhalational botulism in adults and children >1 year if sufficient supplies of botulism antitoxin were not available.
Clothing and skin exposed to aerosolised botulinum toxin should be washed thoroughly with soap and water. As hours to days are required for natural degradation of the toxin, a 0.1% hypochlorite bleach solution should be used to clean exposed objects and surfaces.[50]
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