Standard first-line management of botulism combines supportive care with heptavalent equine-derived botulinum antitoxin (BAT), administered by intravenous infusion. The antitoxin is expected to arrest the advance of flaccid paralysis.

When the First Line Has Not Achieved Its Goal

This protocol applies when neurologic signs continue to progress for more than 1 day after the first BAT dose has had time to take effect — meaning the initial antitoxin treatment has not halted paralysis progression as expected and clinical suspicion for botulism remains high.

Next-Line Approach

In select cases meeting strict clinical criteria, re-administration of antitoxin is the next step considered. The full decision criteria, eligible patient characteristics, and clinical algorithm are detailed in the complete protocol.

References

Do not give patients with suspected botulism a second dose of BAT unless progression of paralysis clearly continues after the initial dose should have taken effect and suspicion for botulism is high.

In the highly rare instance in which it is clinically indicated, a second dose of BAT given within 2 weeks is unlikely to result in a hypersensitivity reaction related to sensitization caused by the first dose because it usually takes longer for the immune system to respond to a new antigen.

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Botulism — What to Do When Neurologic Signs Keep Progressing After the First BAT Dose

When the First Line Has Not Achieved Its Goal

Next-Line Approach

References