para>Safety of botulism antitoxin during pregnancy and breastfeeding is unknown and therefore controversial. á
ISSUES FOR REFERRAL
- Nutrition: Patients with persistent dysphagia may need hyperalimentation or enteral feeding (6)[A].
- Physical/occupational/speech therapy including swallow evaluation and rehabilitation (6)[A]
ADDITIONAL THERAPIES
- Stress ulcer and deep vein thrombosis prophylaxis
- Pulmonary and physical rehabilitation
SURGERY/OTHER PROCEDURES
Wound excision/d ębridement for wound botulism á
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Admit all suspected cases.
- Meticulous airway management
IV Fluids
Keep patient well-hydrated. á
Nursing
- Prevent decubitus ulcers, IV line infections, and other nosocomial infections.
- Before administering antitoxin, perform skin testing for sensitivity.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Outpatient follow-up with physical/occupational therapy, nutrition specialist, and psychiatry, as needed á
Patient Monitoring
- Pulmonary function testing
- Cardiorespiratory monitoring
DIET
Nasogastric feedings, if needed á
PATIENT EDUCATION
- Spores destroyed by pressure cooking at 250 ░F (120 ░C) for 30 minutes (1)
- Toxin destroyed by boiling for 10 minutes (1)
- Avoid honey in 1st year of life (1).
- Avoid IV drug use.
- Do not eat/sample foods that look and smell rotten or come from bulging cans.
PROGNOSIS
- Prompt recognition and antitoxin administration is the most important factor affecting clinical course and outcome (7)[A].
- Mortality: overall, 3-5%; reduced from a near-50% mortality, usually from respiratory failure (7)[A]
- Patients may have significant health, functional, and social limitations several years after infection (7):
- Recovery follows neuromuscular synaptic regeneration.
- 2 to 8 weeks of ventilator support may be required in severe cases.
- Patients who survive generally have a good prognosis.
- Dyspnea, severe ptosis, and pupil abnormalities correlate with severity and predict respiratory failure (9).
COMPLICATIONS
- Complications often associated with prolonged paralysis (i.e., aspiration and ventilator-associated pneumonia, pressure ulcers, muscle wasting)
- Death in severe cases
REFERENCES
11 Centers for Disease Control and Prevention. Botulism facts for healthcare providers. http://www.bt.cdc.gov/agent/Botulism/clinicians/epidemiology.asp. Accessed July 11, 2015.22 Centers for Disease Control and Prevention. National enteric disease surveillance: botulism annual summary, 2012. http://www.cdc.gov/nationalsurveillance/PDFs/Botulism_CSTE_2012.pdf. Accessed July 11, 2015.33 Espelund áM, Klaveness áD. Botulism outbreaks in natural environments-an update. Front Microbiol. 2014;5:287.44 Date áK, Fagan áR, Crossland áS, et al. Three outbreaks of foodborne botulism caused by unsafe home canning of vegetables-Ohio and Washington, 2008 and 2009. J Food Prot. 2011;74(12):2090-2096.55 Dembek áZF, Smith áLA, Rusnak áJM. Botulism: cause, effects, diagnosis, clinical and laboratory identification, and treatment modalities. Disaster Med Public Health Prep. 2007;1(2):122-134.66 Wheeler áC, Inami áG, Mohle-Boetani áJ, et al. Sensitivity of mouse bioassay in clinical wound botulism. Clin Infect Dis. 2009;48(12):1669-1673.77 Chalk áCH, Benstead áTJ, Keezer áM. Medical treatment for botulism. Cochrane Database Syst Rev. 2014;(2):CD008123.88 Vanella de Cuetos áEE, Fernandez áRA, Bianco áMI, et al. Equine botulinum antitoxin for the treatment of infant botulism. Clin Vaccine Immunol. 2011;18(11):1845-1849.99 Witoonpanich áR, Vichayanrat áE, Tantisiriwit áK, et al. Survival analysis for respiratory failure in patients with food-borne botulism. Clin Toxicol (Phila). 2010;48(3):177-183.1010 Pifko áE, Price áA, Sterner áS. Infant botulism and indications for administration of botulism immune globulin. Pediatr Emerg Care. 2014;30(2):120-124.
ADDITIONAL READING
Hill áSE, Iqbal áR, Cadiz áCL, et al. Foodborne botulism treated with heptavalent botulism antitoxin. Ann Pharmacother. 2013;47(2):e12. á
SEE ALSO
Food Poisoning, Bacterial á
CODES
ICD10
- A05.1 Botulism food poisoning
- A48.52 Wound botulism
- A48.51 Infant botulism
ICD9
- 005.1 Botulism food poisoning
- 040.42 Wound botulism
- 040.41 Infant botulism
SNOMED
- Infection due to clostridium botulinum (disorder)
- Foodborne botulism (disorder)
- Wound botulism (disorder)
- Infantile botulism
CLINICAL PEARLS
- Botulism is typically diagnosed based on clinical suspicion.
- Administer botulinum antitoxin as soon as disease is clinically suspected.
- Contact state health authorities to report suspected cases.
- The "dozen D's"Ł (the clinical progression of botulism): dry mouth, diplopia, dilated pupils, droopy eyes, droopy face, diminished gag reflex, dysphagia, dysarthria, dysphonia, difficulty in lifting head, descending paralysis, and diaphragmatic paralysis