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BOTULINUM TOXIN: DIAGNOSIS, TREATMENT AND POSTEXPOSURE PROPHYLAXIS

Diagnosis
The diagnosis of botulism requires recognition of the key clinical features. Clinical samples used for naturally occurring disease include direct detection of botulinum toxin and identification of C. botulinum by culture of serum (>30 ml of blood in a red-top tube), stool, gastric aspirate, vomitus, and suspected food. In a bioterrorism aerosol release, serology would be the primary method of diagnosis. Toxins produced by cultured isolates are confirmed by a mouse bioassay.
Treatment and postexposure prophylaxis
Treatment consists of supportive care and passive immunization with a trivalent equine antitoxin. Supportive care may include enteral nutrition, ventilatory support, and treatment of secondary infections. The reverse Trendelenburg position is recommended for non-ventilated patients to prevent aspiration of secretions. Administration of the trivalent (containing types A, B, and E) equine antitoxin, available only through the CDC, should occur immediately after a clinical diagnosis is made and should not await laboratory confirmation. This can minimize subsequent nerve damage and reduce the severity of disease but does not reverse existent paralysis. The dose of licensed botulinum antitoxin is a single 10 ml vial per patient, diluted 1:10 in a 0.9% saline solution, and administered by slow intravenous infusion. Since hypersensitivity reactions are common with the antitoxin, skin testing is usually performed as a screening tool. If hypersensitivity is identified, patients can be desensitized before additional antitoxin is given.
It is unclear how best to care for patients who may have been exposed to botulinum toxin but who are not yet ill. The use of the trivalent equine antitoxin is limited by it scarcity and risk of hypersensitivity. An investigational pentavalent (ABCDE) botulinum toxoid is used by CDC laboratory workers at high risk and by the military for protection of troops against attack. A recombinant vaccine is also in development.
Infection Control
Since person-to-person spread of botulism does not occur, no isolation is necessary. Physicians should use standard precautions when caring for patients with botulism.
*214/348/5*

BOTULINUM TOXIN: DIAGNOSIS, TREATMENT AND POSTEXPOSURE PROPHYLAXIS DiagnosisThe diagnosis of botulism requires recognition of the key clinical features. Clinical samples used for naturally occurring disease include direct detection of botulinum toxin and identification of C. botulinum by culture of serum (>30 ml of blood in a red-top tube), stool, gastric aspirate, vomitus, and suspected food. In a bioterrorism aerosol release, serology would be the primary method of diagnosis. Toxins produced by cultured isolates are confirmed by a mouse bioassay.

Treatment and postexposure prophylaxisTreatment consists of supportive care and passive immunization with a trivalent equine antitoxin. Supportive care may include enteral nutrition, ventilatory support, and treatment of secondary infections. The reverse Trendelenburg position is recommended for non-ventilated patients to prevent aspiration of secretions. Administration of the trivalent (containing types A, B, and E) equine antitoxin, available only through the CDC, should occur immediately after a clinical diagnosis is made and should not await laboratory confirmation. This can minimize subsequent nerve damage and reduce the severity of disease but does not reverse existent paralysis. The dose of licensed botulinum antitoxin is a single 10 ml vial per patient, diluted 1:10 in a 0.9% saline solution, and administered by slow intravenous infusion. Since hypersensitivity reactions are common with the antitoxin, skin testing is usually performed as a screening tool. If hypersensitivity is identified, patients can be desensitized before additional antitoxin is given.It is unclear how best to care for patients who may have been exposed to botulinum toxin but who are not yet ill. The use of the trivalent equine antitoxin is limited by it scarcity and risk of hypersensitivity. An investigational pentavalent (ABCDE) botulinum toxoid is used by CDC laboratory workers at high risk and by the military for protection of troops against attack. A recombinant vaccine is also in development.
Infection ControlSince person-to-person spread of botulism does not occur, no isolation is necessary. Physicians should use standard precautions when caring for patients with botulism.*214/348/5*

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