Botulism - Treatment

Regimen and diet for botulism

Treatment of botulism primarily involves prescribing bed or semi-bed rest.

Diet: table No. 10, tube or parenteral nutrition depending on the patient’s condition.

Enteral nutrition is administered through a nasogastric tube, while it is necessary to remember that gastric feeding is preferable to duodenal feeding. The technique is infusion for 16 hours. Nutritional mixtures with high energy density are preferable (for example, "Isocal HCN", "Osmolite HN"), in case of respiratory failure - "Pulmocare". The volume of protein per day is determined based on 25 kcal / kg of body weight and 1.5 g / kg of body weight. In case of stagnant discharge from the stomach, they switch to parenteral nutrition with mandatory partial enteral nutrition at the rate of 2000-2500 kcal per day for an adult patient. Parenteral nutrition is carried out with concentrated glucose solutions (10-40%), amino acid mixtures and fat emulsions.

Drug treatment of botulism

Treatment of botulism consists of the administration of antitoxic antibotulinum serum. Heterologous (equine) antitoxic monovalent serums are used. If the type of toxin is unknown, a mixture of monovalent serums or polyvalent serum (10 thousand IU of anatoxin types A and E and 5 thousand NLE of anatoxin type E) is administered. Regardless of the severity of the course, one therapeutic dose of serum diluted in 200 ml of warmed isotonic sodium chloride solution is administered intravenously. To prevent anaphylactic reactions, 60-90 mg of prednisolone is administered before the administration of the serum. The serum is administered once. Before the administration of the serum, the Bezredka test is performed with serum diluted 100 times. The presence of an allergic reaction when performing the test serves as a relative contraindication to the administration of a therapeutic dose of serum. In these cases, the preliminary dose of prednisolone is increased to 240 mg.

Specific antitoxic treatment for botulism involves the administration of human antibotulinum immunoglobulin.

In severe cases, treatment of botulism is primarily aimed at replacing or activating temporarily lost body functions. For this, certain principles of therapy are used.

• Reducing the risk and consequences of aspiration of gastric contents into the respiratory tract.
  • Permanent nasogastric tube; in case of stagnant discharge - periodic gastric lavage.
  • In case of high risk of aspiration, prolonged intubation with a constantly inflated cuff. (25 cm H2O is the maximum pressure that does not cause damage to the trachea. It is important to remember that inflating the cuff of the tracheal tubes does not eliminate the risk of aspiration of oral secretions into the lower respiratory tract.) In this case, breathing is carried out through the ventilator circuit (usually one of the methods of auxiliary ventilation is used), since adequate heating and humidification of the breathing mixture is necessary.
  • Prescribed drugs that reduce the acidity of gastric juice: ranitidine, famotidine, proton pump blockers (omeprazole, esomeprazole, rabeprazole).
  • Drugs that improve the motor function of the gastrointestinal tract (domperidone, metoclopramide).
• Treatment of respiratory failure.
  • Patient fatigue during breathing, minimal sensation of shortness of breath, increase in pCO2, >53 mm Hg are indications for transferring the patient to assisted ventilation (even if there is no dyspnea, involvement of accessory muscles, cyanosis and other symptoms of acute respiratory failure). Examples: CPAP (continuous positive airway pressure), reduces the work of breathing; MMV (guaranteed minute volume). The patient is given a stable minute volume - 6 l/min is acceptable. If the spontaneous ventilation volume is 4 l/min, the patient will receive the remaining 2 l/min using a respirator. PS (pressure support): for each inhalation attempt by the patient, the respirator brings the tidal volume to the set pressure (20 cm H2O is acceptable).
  • Warming and humidifying the respiratory mixture, stimulating the movement of sputum (chest percussion, vibration, vacuum massage), removing sputum (postural drainage, its aspiration), oxygenation.
  • Normalization of acid-base balance, hemoglobin levels, circulating blood volume, cardiac output, body temperature, and plasma electrolyte composition.

In case of myocardial damage, it is necessary to prescribe myocardial cytoprotectors (trimetazidine, carnitine, meldonium). The development of bacterial complications requires the prescription of broad-spectrum antibacterial drugs. The administration of immunoglobulins (normal human immunoglobulin: octagam, pentaglobin) is indicated at all stages of the disease.

A special intensive treatment for botulism, given the complex nature of hypoxia, is hyperbaric oxygenation.

All patients are prescribed chloramphenicol 0.5 g four times a day for 5 days to suppress the activity of botulism pathogens in the gastrointestinal tract and prevent possible toxin formation. Instead of chloramphenicol, ampicillin 0.5-1 g four times a day orally can be used.

In cases of wound botulism, appropriate surgical treatment of the wound is performed, and increased doses (up to 12-16 million U/day) of penicillin or other antibiotics are used.

Patients are discharged after clinical recovery.

Approximate periods of incapacity for work

The periods of incapacity vary greatly and are determined individually.

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Clinical examination

Not regulated. It is advisable to have observation for at least 6 months with the participation of a neurologist, ophthalmologist and cardiologist.

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What is the prognosis for botulism?

With early administration of antibotulinum serum, the outcome is favorable. Fatal outcomes are observed with late hospitalization, in individuals with a complicated premorbid background.

How to prevent botulism?

Specific prevention of botulism

If cases of the disease are detected, suspicious products are subject to confiscation and laboratory testing, and those who consumed them together with the sick persons are subject to medical observation for 10-12 days. It is advisable to treat botulism by intramuscular injection of 2000 IU of antitoxic antibotulinum serums of types A, B and E, and to prescribe enterosorbents. Active immunization is indicated only for persons who have or may have contact with botulinum toxins. Vaccinations are carried out with polyanatoxin three times with intervals of 45 days between the first and second and 60 days between the second and third vaccinations.

Nonspecific prevention of botulism

Prevention of botulism consists of strict adherence to the rules for the preparation and storage of fish and meat semi-finished products, canned goods, smoked meats, etc. Home-made canned goods, especially mushrooms, are dangerous, since their artisanal production does not provide for heat treatment, which has a detrimental effect on the spores of botulism pathogens. That is why before using such products, it is advisable to boil them in a water bath for 10-15 minutes, which achieves complete neutralization of the botulinum toxin. However, it is necessary to remember that this kills the toxin, not the spore forms, so when reusing the product, boiling must be repeated. In the prevention of botulism, sanitary education of the population regarding the preparation of food products that can cause poisoning with botulinum toxins is of great importance.