Injectional Botulism in Adults, Management Guideline


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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Clinical presentation

Descending symmetrical paralysis, typically starting with diplopia, dysarthria and ptosis. There is an absence of fever, meningism, confusion, impaired conscious level and sensory signs. Rapid progression to respiratory failure can occur with autonomic dysfunction. Injectional botulism typically occurs following injection of contaminated heroin into muscle or skin, with an incubation period of around 7 days. Botulism is a clinical diagnosis, EMG studies can assist, microbiology results may be negative.

Microbiological diagnosis

Testing for botulism takes several days in a reference lab. Treatment should not be deferred pending results. Samples should be sent urgently to the microbiology lab following discussion with the microbiologist. Clinical information section must be completed on reference lab request form.

  • Serum for botulinum toxin, at least 10ml in gold topped serum gel tube (must be taken before botulinum anti-toxin is given)
  • Pus or debrided tissue for culture and PCR in a plain universal container. Do not send swabs of pus.

Antibiotic treatment – kills viable C. botulinum

  • IV benzylpenicillin 2.4g 6 hourly and IV metronidazole 500mg 8 hourly
  • IV Vancomycin ( See GG&C vancomycin dose calculator) plus IV metronidazole 500mg 8 hourly, if allergic to penicillin
  • Try to avoid gentamicin and clindamycin as this may increase neuromuscular blockade
  • Seek advice from Infectious Disease or Microbiologist re duration
  • Other antibiotics may be needed to treat co-existing soft tissue infection.

Botulinum Anti‐toxin ‐ binds free botulinum toxin.

IV Anti‐toxin should be administered as soon as possible. For supplies contact GRI pharmacy or GRI pharmacist on‐call. The dosing schedule is summarised below but please check product information leaflet. Emergent Biosolutions: Adult dose – contents of 1 vial after dilution 1:10 in normal saline. Administer by slow IV infusion, initially 0.5ml/min, doubling the rate if tolerated every 30min to a maximum 2ml/min. Monitor for infusion reactions. For dosage in children see product information leaflet.

Debridement - removes source of C. botulinum

Any injection sites should be urgently debrided to remove the source of further toxin production, even if there is no evidence of serious infection.

Critical care review

Respiratory failure can occur rapidly. ITU should be informed of any suspected cases. 

Public Health notification

Botulism is a notifiable disease. Inform the on-call Public Health consultant on Phone: 0141 201 4917 Out of hours: 0141 201 3600

Infection Control

Patients with suspected C. botulinum require no special infection control measures.

Last reviewed: 31 May 2019

Next review: 31 August 2022

Author(s): Erica Peters

Version: 3

Approved By: Antimicrobial Authorisation Committee

Document Id: 338