Medical treatment for botulism

Abstract

Background: Botulism is an acute paralytic illness caused by a neurotoxin produced by Clostridium botulinum. Supportive care, including intensive care, is key, but the role of other medical treatments is unclear. This is an update of a review first published in 2011.

Objectives: To assess the effects of medical treatments on mortality, duration of hospitalization, mechanical ventilation, tube or parenteral feeding, and risk of adverse events in botulism.

Search methods: We searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase on 23 January 2018. We reviewed bibliographies and contacted authors and experts. We searched two clinical trials registers, WHO ICTRP and clinicaltrials.gov, on 21 February 2019.

Selection criteria: Randomized controlled trials (RCTs) and quasi-RCTs examining the medical treatment of any of the four major types of botulism (infant intestinal botulism, food-borne botulism, wound botulism, and adult intestinal toxemia). Potential medical treatments included equine serum trivalent botulism antitoxin, human-derived botulinum immune globulin intravenous (BIG-IV), plasma exchange, 3,4-diaminopyridine, and guanidine.

Data collection and analysis: We followed standard Cochrane methodology.Our primary outcome was in-hospital death from any cause occurring within four weeks from randomization or the beginning of treatment. Secondary outcomes were death from any cause occurring within 12 weeks, duration of hospitalization, duration of mechanical ventilation, duration of tube or parenteral feeding, and proportion of participants with adverse events or complications of treatment.

Main results: A single RCT met the inclusion criteria. Our 2018 search update identified no additional trials. The included trial evaluated BIG-IV for the treatment of infant botulism and included 59 treatment participants and 63 control participants. The control group received a control immune globulin that did not have an effect on botulinum toxin. Participants were followed during the length of their hospitalization to measure the outcomes of interest. There was some violation of intention-to-treat principles, and possibly some between-treatment group imbalances among participants admitted to the intensive care unit and mechanically ventilated, but otherwise the risk of bias was low. There were no deaths in either group, making any treatment effect on mortality inestimable. There was a benefit in the treatment group on mean duration of hospitalization (BIG-IV: 2.60 weeks, 95% confidence interval (CI) 1.95 to 3.25; control: 5.70 weeks, 95% CI 4.40 to 7.00; mean difference (MD) -3.10 weeks, 95% CI -4.52 to -1.68; moderate-certainty evidence); mechanical ventilation (BIG-IV: 1.80 weeks, 95% CI 1.20 to 2.40; control: 4.40 weeks, 95% CI 3.00 to 5.80; MD -2.60 weeks, 95% CI -4.06 to -1.14; low-certainty evidence); and tube or parenteral feeding (BIG-IV: 3.60 weeks, 95% CI 1.70 to 5.50; control: 10.00 weeks, 95% CI 6.85 to 13.15; MD -6.40 weeks, 95% CI -10.00 to -2.80; moderate-certainty evidence), but not on proportion of participants with adverse events or complications (BIG-IV: 63.08%; control: 68.75%; risk ratio 0.92, 95% CI 0.72 to 1.18; absolute risk reduction 0.06, 95% CI 0.22 to -0.11; moderate-certainty evidence).

Authors' conclusions: We found low- and moderate-certainty evidence supporting the use of BIG-IV in infant intestinal botulism. A single RCT demonstrated that BIG-IV probably decreases the duration of hospitalization; may decrease the duration of mechanical ventilation; and probably decreases the duration of tube or parenteral feeding. Adverse events were probably no more frequent with immune globulin than with placebo. Our search did not reveal any evidence examining the use of other medical treatments including serum trivalent botulism antitoxin.

Figure 1

Study flow diagram.

Figure 2

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study. Red = high risk of bias; yellow = unclear risk of bias (not shown); green = low risk of bias.

Figure 3

Forest plot of comparison: 1 Human‐derived botulinum immune globulin intravenous, outcome: 1.5 Duration of hospitalization (weeks).

Figure 4

Forest plot of comparison: 1 Human‐derived botulinum immune globulin intravenous, outcome: 1.6 Duration of mechanical ventilation (weeks).

Figure 5

Forest plot of comparison: 1 Human‐derived botulinum immune globulin intravenous, outcome: 1.7 Duration of tube or parenteral feeding (weeks).

Analysis 1.1

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 1 In‐hospital death from any cause occurring within 4 weeks of randomization or the beginning of treatment.

Analysis 1.2

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 2 In‐hospital death from any cause occurring within 4 weeks of randomization or the beginning of treatment.

Analysis 1.3

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 3 Death from any cause occurring within 12 weeks of randomization or the beginning of treatment.

Analysis 1.4

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 4 Death from any cause occurring within 12 weeks of randomization or the beginning of treatment.

Analysis 1.5

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 5 Duration of hospitalization (weeks).

Analysis 1.6

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 6 Duration of mechanical ventilation (weeks).

Analysis 1.7

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 7 Duration of tube or parenteral feeding (weeks).

Analysis 1.8

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 8 Adverse events.

Analysis 1.9

Comparison 1 Human‐derived botulinum immune globulin intravenous, Outcome 9 Adverse events.