What is the recommended treatment for botulism in infants and adults?

Treatment of Botulism

Immediate Management: Contact CDC and Administer Antitoxin

Healthcare providers who suspect botulism based on clinical symptoms should immediately call their local or state health department emergency contact number to arrange for emergency clinical consultation and shipment of antitoxin, ideally within 24 hours of symptom onset. 1

Critical First Steps

• Call the CDC 24-hour botulism consult service immediately upon clinical suspicion—do not wait for laboratory confirmation, as testing often takes 24-48 hours or longer and antitoxin effectiveness decreases dramatically after 24 hours 1, 2
• Recognize that almost all patients can survive with supportive care alone, but antitoxin stops progression of paralysis and prevents respiratory compromise when given early 1
• Understand that antitoxin cannot reverse existing paralysis—it only neutralizes circulating toxin not yet bound to nerve endings 1

Adult and Pediatric Treatment (Non-Infant)

Standard Dosing

• Adults receive one vial of heptavalent botulinum antitoxin (BAT) by intravenous infusion, containing approximately 10^7 IU of antitoxins A, B, C, and F 1, 3
• Children aged 1-16 years receive 20%-100% of the adult dose based on weight categories using the Salisbury rule (double body weight for <66 lb to determine percentage; add 66 lb to body weight for >66 lb) 1, 3
• Monitor children closely for worsening paralysis despite weight-based dosing, as toxin load is not proportional to body weight but rather to amount ingested 1, 3

Retreatment Considerations

• Do not give a second dose of BAT unless paralysis clearly continues to progress after the initial dose should have taken effect (antitoxin half-life ranges 7.5-34 hours) 1
• If neurologic signs progress for >1 day after BAT administration, strongly consider alternative diagnoses rather than automatically retreating 1
• A second dose within 2 weeks is unlikely to cause hypersensitivity reactions, as immune sensitization typically takes longer 1

Infant Botulism: Critical Distinction

Foodborne Botulism in Infants vs. Infant Botulism Syndrome

The treatment differs dramatically based on whether the infant has foodborne botulism (ingested preformed toxin) or infant botulism syndrome (intestinal colonization with in situ toxin production). 1, 2

Foodborne Botulism in Infants

• Infants with foodborne botulism receive BAT at 10% of the adult dose (FDA-approved dosing regardless of weight) 1, 3
• This applies when an infant is part of a group outbreak or has documented exposure to contaminated food 1, 2
• Do NOT use BabyBIG (human botulism immune globulin) for foodborne botulism—it is reserved exclusively for infant botulism syndrome 2

Infant Botulism Syndrome (Intestinal Colonization)

• Single sporadic cases in infants are presumed to be infant botulism syndrome and should receive BabyBIG (human-origin anti-A, anti-B botulinum antitoxin) 1
• Contact the California Department of Public Health Infant Botulism Treatment and Prevention Program for BabyBIG 1, 4
• BabyBIG reduces mean hospital stay from 5.7 weeks to 2.6 weeks, mechanical ventilation by 2.6 weeks, and tube feeding by 6.4 weeks 5, 6
• Treatment within 7 days of admission produces better outcomes than later treatment 5

Supportive Care: The Foundation of Survival

Modern mortality rates are <5% (down from 70% historically) primarily due to intensive supportive care, particularly mechanical ventilation, not antitoxin alone. 1

Essential Supportive Measures

• Prepare for mechanical ventilation—approximately 50% of infant botulism cases and many adult cases require intubation 1, 4
• Provide nutritional support via tube or parenteral feeding for prolonged periods (weeks to months) 1, 6
• Admit to intensive care unit for close neurologic and respiratory monitoring 2, 7
• Monitor for complications including sepsis, which occurs less frequently with early antitoxin treatment 8

Clinical Recognition: Key Diagnostic Features

• Look for afebrile presentation with acute onset of cranial nerve findings: blurred vision, diplopia, ptosis, fixed/dilated pupils, dysphagia, dysarthria, facial paresis 2, 7
• Descending paralysis pattern with normal sensation and mentation distinguishes botulism from other neuromuscular disorders 7, 4
• Autonomic dysfunction may be present 7

Common Pitfalls to Avoid

• Never delay antitoxin administration waiting for laboratory confirmation—clinical diagnosis is sufficient and testing takes days 1, 2, 4
• Do not confuse infant botulism syndrome with foodborne botulism in an infant—the treatments differ (BabyBIG vs. BAT) 1, 2
• Do not use weight-based dosing as the sole guide in children—toxin load depends on amount ingested, not body weight, so monitor closely for inadequate response 1
• Avoid routine second dosing—progression beyond 24 hours should prompt reconsideration of the diagnosis rather than automatic retreatment 1
• Recovery takes weeks to months with prolonged fatigue lasting years, so set appropriate expectations with patients and families 7