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.[41]
Swift administration of botulism antitoxin is also essential in the management of botulism cases.[41] In March 2010, the 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 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.[63] The potential for anaphylaxis, delayed allergic reactions (serum sickness), and lifelong sensitization 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.[64]
Human-derived botulism immunoglobulin (known as BabyBIG™, available from the California Department of Health Services) has been shown to be safe and effective for treatment of infected infants in a randomized, controlled trial.[64][65] Infant Botulism Treatment and Prevention Program Opens in new window
Foodborne botulism
Toxin types A, B, and E account for most cases of foodborne botulism. Adults and children ≥1 year of age should receive heptavalent botulism antitoxin (HBAT, Cangene Corporation), and infants <1 year 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 sensitization to equine proteins.[64]
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 HBAT, and 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 penicillin G, 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.[66]
Iatrogenic botulism
The US Food and Drug Administration licensed type A and type B botulinum toxin preparations for therapeutic and cosmetic purposes. In cases of iatrogenic botulism, HBAT 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 (biologic 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 state health department and hospital infection control department should be notified immediately. However, there are no specific reporting requirements outside of the requirement to report any case of botulism.
In the event of intentional dissemination of botulinum toxin, heptavalent antitoxin may be dispensed for adults and children by the Department of Defense. 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 aerosolized 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.[47]
Use of botulism antitoxin as a means of postexposure prophylaxis has not been shown to be effective. Current recommendations by the 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.
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