Ophthalmologic Manifestations of Botulism Treatment & Management

Updated: May 19, 2016
  • Author: Bhupendra C K Patel, MD, FRCS; Chief Editor: Hampton Roy, Sr, MD  more...
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Approach Considerations

As botulism neurotoxin binds irreversibly, administration of antitoxin does not reverse paralysis. Neurologic recovery occurs only when motor neurons regenerate, which may take weeks to months. Therefore, intensive respiratory and nutritional support is vital.


Medical Care

Supportive care for the duration of the paralytic illness, with extensive nursing support, is the mainstay of treatment.

Ventilatory support: In adults, ventilatory support will be needed in as many as one third of cases. Pulse oximetry, arterial blood gas analysis, and spirometry should be monitored. Mechanical ventilation is considered when vital capacity is less than 30% of predicted.

Parenteral nutrition may be required in view of gastrointestinal disturbance.

Urinary catheterization may be required for urinary retention.


In food-borne illness, trivalent (types A, B, and E) equine antitoxin should be administered, with antitoxin neutralizing botulinum toxin not yet bound to nerve terminals. Therefore, the antitoxin should be given as soon as possible, prior to receiving laboratory confirmation of diagnosis. Antitoxin neutralizes circulating neurotoxin molecules that have not yet bound to nerve endings. The recommended dose of botulism antitoxin in adults is one vial per patient as a single dose. Hypersensitivity reaction to the antitoxin occur in about 9% of patients treated with equine sera, so skin testing should be performed before administration.

Botulism immune globulin intravenous

Botulism immune globulin intravenous (human) (BIG-IV; also called BabyBig) is FDA-approved for the treatment of infant botulism caused by C botulinum type A or type B. It should be administered urgently and has been shown to be safe and effective. It reduces mean hospital stay per case from 5.5 weeks to 2.5 weeks. Administration of BIG-IV has also been shown to decrease days of mechanical ventilation, days of intensive care unit stay, and overall hospital stays.

Antibiotic therapy

Antibiotics may be helpful in the eradication of C botulinum in wound botulism, but they appear to have no role in infant botulism or in botulism of food poisoning. Remember that aminoglycoside antibiotics and tetracyclines may increase neuromuscular blockade by impairment of neuronal calcium entry and may potentiate the toxin paralytic effects, precipitating acute respiratory arrest in infants with unsuspected botulism patients.

Antibiotics are otherwise reserved for treatment of secondary bacterial infections (eg, pneumonia, urinary tract infections).


Surgical Care

Wound botulism requires exploration and wound debridement immediately after antitoxin administration. Anaerobic cultures should be obtained and penicillin at 250,000-400,000 U/kg/day for 10-14 days is administered.