Botulism

Plus – botulism antitoxin

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1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

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.

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Plus –

botulism antitoxin

Treatment recommended for ALL patients in selected patient group

Swift administration of antitoxin is essential.[44]

Toxin types A, B, and E account for most cases of foodborne botulism.

Several types of botulism antitoxin are available, which may differ in presentation, composition, dosage, and administration.

No specific dose recommendations can be made due to the variability of the properties (e.g., 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 2013, the US Food and Drug Administration approved the use of the heptavalent botulism antitoxin (HBAT). HBAT, available only through the US Centers for Disease Control and Prevention (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] A dose of HBAT contains equine-derived antibody to 7 botulinum toxin types (A-G) with a minimum potency of 4500 units of serotype A antitoxin, 3300 units of serotype B antitoxin, 3000 units of serotype C antitoxin, 600 units of serotype D antitoxin, 5100 units of serotype E antitoxin, 3000 units of serotype F antitoxin, and 600 units of serotype G antitoxin.

Primary options

botulism antitoxin: consult specialist for guidance on dose

Consider – gastric lavage or enemas

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Consider –

gastric lavage or enemas

Additional treatment recommended for SOME patients in selected patient group

Gastric lavage may be attempted if the food exposure was relatively recent.

In the absence of an ileus, enemas may be used to eliminate unabsorbed toxin from the gastrointestinal tract.

Back

1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

Respiratory status must be monitored closely through frequent monitoring of patient’s respiratory rate, pulse oximetry, and arterial blood gases, as needed.

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.

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botulism immunoglobulin

Treatment recommended for ALL patients in selected patient group

Swift administration of intravenous botulism immunoglobulin (human), also known as BabyBIG™, is essential in infants <1 year of age with botulism type A or B.

It has been shown to be safe and effective for the treatment of infected infants in a randomised, controlled trial. Treatment was associated with reduction in the mean length of hospital stay, duration of mechanical ventilation, and associated costs when compared with treatment with intravenous immunoglobulin.[66][67]

A single dose is used in suspected or confirmed cases. Its half-life is 28 days.

Information and supply is from the California Department of Health Services.[53] Infant Botulism Treatment and Prevention Program Opens in new window

Human-derived botulism immunoglobulin is preferred in the infant (<1 year) population because antitoxins derived from equine plasma (such as heptavalent botulism antitoxin) have shorter half-lives, and have been associated with anaphylaxis, delayed allergic reactions (serum sickness), and lifelong sensitisation to equine proteins.[66]

Primary options

botulism immunoglobulin (human): dose may vary with each manufactured lot; consult specialist for guidance on dose

wound botulism

Plus – botulism antitoxin

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1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

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.

Back

Plus –

botulism antitoxin

Treatment recommended for ALL patients in selected patient group

Swift administration of antitoxin is essential.[44]

For wound botulism equine antitoxin is available at specific UK centres.

Several types of botulism antitoxin are available, which may differ in presentation, composition, dosage, and administration.

No specific dose recommendations can be made, due to the variability of the properties (e.g., strength of the available antitoxin in different countries). Therefore, the product particular supplied with the vial(s) must be consulted.

Primary options

botulism antitoxin: consult specialist for guidance on dose

Plus – debridement and antibiotics

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Plus –

debridement and antibiotics

Treatment recommended for ALL patients in selected patient group

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]

Primary options

debridement

and

benzylpenicillin sodium: children: consult specialist for guidance on dose; adults: 2.4 to 4.8 g/day intravenously/intramuscularly given in divided doses every 6 hours

Secondary options

debridement

and

metronidazole: children: consult specialist for guidance on dose; adults: 500 mg intravenously every 8 hours

Back

1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

Respiratory status must be monitored closely through frequent monitoring of patient’s respiratory rate, pulse oximetry, and arterial blood gases, as needed.

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.

Plus – debridement and antibiotics

Back

Plus –

botulism immunoglobulin

Treatment recommended for ALL patients in selected patient group

Swift administration of intravenous botulism immunoglobulin (human), also known as BabyBIG™, is essential in infants <1 year of age with botulism type A or B.

A single dose is used in suspected or confirmed cases. Its half-life is 28 days.

Information and supply is from the California Department of Health Services.[53] Infant Botulism Treatment and Prevention Program Opens in new window

Primary options

botulism immunoglobulin (human): dose may vary with each manufactured lot; consult specialist for guidance on dose

Back

Plus –

debridement and antibiotics

Treatment recommended for ALL patients in selected patient group

Patients with wound botulism should undergo careful debridement.

Primary options

debridement

and

benzylpenicillin sodium: children: consult specialist for guidance on dose

Secondary options

debridement

and

metronidazole: children: consult specialist for guidance on dose

iatrogenic botulism

Plus – botulism antitoxin

Back

1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

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.

Back

Plus –

botulism antitoxin

Treatment recommended for ALL patients in selected patient group

Swift administration of antitoxin is essential.[44]

Type A and type B botulinum toxin preparations are currently licensed for therapeutic and cosmetic purposes. In cases of iatrogenic botulism, the antitoxin containing types A, B, and E should be administered to adults and children ≥1 year of age.

In March 2013, the US Food and Drug Administration (FDA) approved the use of the heptavalent botulism antitoxin (HBAT). HBAT, available only through the US Centers for Disease Control and Prevention (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] A dose of HBAT contains equine-derived antibody to 7 botulinum toxin types (A-G) with a minimum potency of 4500 units of serotype A antitoxin, 3300 units of serotype B antitoxin, 3000 units of serotype C antitoxin, 600 units of serotype D antitoxin, 5100 units of serotype E antitoxin, 3000 units of serotype F antitoxin, and 600 units of serotype G antitoxin.

Primary options

botulism antitoxin: consult specialist for guidance on dose

Back

1st line –

supportive care

Supportive care is the mainstay of botulism therapy.[44]

Respiratory status must be monitored closely through frequent monitoring of patient’s respiratory rate, pulse oximetry, and arterial blood gases, as needed.

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.

Back

Plus –

botulism immunoglobulin

Treatment recommended for ALL patients in selected patient group

Swift administration of intravenous botulism immunoglobulin (human), also known as BabyBIG™, is essential in infants <1 year of age with botulism type A or B.

A single dose is used in suspected or confirmed cases. Its half-life is 28 days.

Information and supply is from the California Department of Health Services. Infant Botulism Treatment and Prevention Program Opens in new window

Primary options

botulism immunoglobulin (human): dose may vary with each manufactured lot; consult specialist for guidance on dose

inhalational botulism (biological attack)

1st line – supportive care and decontamination

Back

1st line –

supportive care and decontamination

Supportive care is the mainstay of botulism therapy.[44]

Adults and children 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.

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]

Plus – botulism antitoxin or botulism immunoglobulin

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Plus –

botulism antitoxin or botulism immunoglobulin

Treatment recommended for ALL patients in selected patient group

Swift administration of antitoxin is essential.[44]

In the event of intentional dissemination of botulinum toxin, passive immunisation with trivalent 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, a heptavalent antitoxin may be dispensed by the Department of Defense.[50]

Botulism immunoglobulin (BabyBIG™) has not been tested in adults or children >1 year.

Primary options

botulism antitoxin: consult specialist for guidance on dose

Secondary options

botulism immunoglobulin (human): dose may vary with each manufactured lot; consult specialist for guidance on dose

1st line – supportive care and decontamination

Back

1st line –

supportive care and decontamination

Supportive care is the mainstay of botulism therapy.[44]

Respiratory status must be monitored closely through frequent monitoring of patient’s respiratory rate, pulse oximetry, and arterial blood gases, as needed.

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.