Q&A: CDC publishes first clinical guidelines for botulism
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For the first time, the CDC has published clinical guidelines for the diagnosis and treatment of botulism.
Agam K. Rao, MD, a medical officer with the CDC’s Division of High Consequence Pathogens and Pathology, and colleagues compiled the recommendations based on data from six systematic reviews on the clinical features of botulism.
“Before the publication of these guidelines, no comprehensive clinical care guidelines existed for treating botulism,” Rao and colleagues wrote in MMWR. “These evidence-based guidelines provide health care providers with recommended best practices for diagnosing, monitoring and treating single cases or outbreaks of foodborne, wound, and inhalational botulism and were developed after a multiyear process involving several systematic reviews and expert input.”
Healio spoke with Leslie Edwards, MHS, BSN, an epidemiologist and botulism expert for the CDC, about the new guidance.
Healio: Why did it take this long to publish guidelines, and why have they now been published?
Edwards: These are the first comprehensive clinical care guidelines for botulism. The guidelines provide clinicians with recommended best practices for diagnosing, treating and monitoring people with most kinds of botulism. CDC developed the guidelines through a multiyear process involving extensive expert input and six systematic reviews of 100 years of literature. We designed the process to ensure as complete a review of the literature as possible and to allow for input from a broad array of scientists with expertise relevant to the clinical care of botulism.
Healio: Which type of botulism is a clinician in the United States most likely to encounter?
Edwards: Foodborne botulism and wound botulism are the two most common types of botulism among adults in the U.S. Incidence for each type varies from year to year. Examining preliminary surveillance data from 2020 and 2021, wound botulism among people who inject heroin (including black tar heroin) and methamphetamines appears to be increasing.
Healio: What are the major risk factors for botulism in the U.S.?
Edwards: The only risk factor for foodborne botulism is eating foods that have been contaminated with botulinum toxin. This includes eating homemade foods that have been improperly canned, preserved or fermented. Foodborne botulism can also happen when certain foods are not adequately refrigerated.
Wound botulism can happen if spores from the bacteria get into a wound and make botulinum toxin. People who inject illicit drugs have a greater chance of getting wound botulism. Wound botulism has also happened in people after traumatic injuries, such as motorcycle accidents or surgeries.
Healio: What are the major recommendations that might be most clinically relevant to a practicing ID clinician?
Edwards: The diagnosis of botulism depends on high clinical suspicion and a thorough neurologic examination. The timeliness of diagnosis is crucial to successful treatment because botulinum antitoxin must be administered to patients as quickly as possible. In patients with wound botulism, it can be difficult to differentiate between the clinical presentation of drug use and botulism. Patients with cranial nerve signs and symptoms or descending paralysis should be asked about their food history and injection drug use in the days before onset of symptoms in order to aid in the diagnosis.
Healio: Why is it important not to wait for laboratory confirmation before treating a patient suspected of having botulism?
Edwards: Botulism testing occurs at state public health department laboratories and at the CDC, and results can take several days. Delaying administration of antitoxin to a patient with suspected botulism can worsen the patient’s outcome.
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