Botulism Antitoxin Guidance

Botulism Antitoxin Guidance

General Principles

  • Toxin-mediated paralytic illness usually caused by Clostridium botulinum and rarely caused by other Clostridium species
  • C. botulinum toxin types that cause human disease include A, B, E, and F
  • Outbreaks of wound botulism have occurred in San Diego County in 2017-2018 (n=9) and 2022

Major syndromes:

  • Foodborne Botulism
    • Causes: Home-canned goods
    • Transmission: Toxin ingested with food in which it was produced
  • Infant Botulism
    • Causes: Honey and other sources due to absence of competing microbiota
    • Transmission: Ingestion of spores → germinate in intestine and produce toxin
  • Wound Botulism
    • Causes: “Black tar” heroin especially in those who “skin- pop” (i.e., drug injection into tissue vs. vein)
    • Transmission: Spores introduced into a wound → germinate and produce toxin

Less common:

  • Iatrogenic Botulism
  • Botulism of undetermined etiology
  • Inhalation Botulism


Need rapid clinical diagnosis of botulism for timely anti-toxin treatment to stop progression of paralysis

  • Acute, bilateral cranial neuropathies (e.g., ptosis, diplopia, dysarthria) associated with progressive symmetrical descending weakness
  • Cardinal features:
    • Fever is absent (unless a complicating infection occurs)
    • Neurological manifestations are symmetrical
    • Patient remains responsive
    • Heart rate is normal/slow in absence of hypotension
    • No sensory deficits (except for blurred vision)
  • Wound botulism has been associated with injection drug use, especially in those skin-popping with “black tar” heroin

Consult early:

  • Infectious Diseases
  • Neurology
  • Test serum and appropriate sites (e.g., wound, feces, etc. based on botulism type) PRIOR to antitoxin as requested and approved by California Department of Public Health (CDPH)
  • Note: results take weeks to return


Administration of Botulism Antitoxin Heptavalent (A, B, C, D, E, F, G – Equine) (BAT®) from CDC within 12 hours of presentation

More Information

  1. Boland Birch T, Bleck TP. (2020). Botulism (Clostridium botulinum) (pp. 2954-2959.e2). Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 9th Edition. Philadelphia, PA: Elsevier.
  2. CAHAN San Diego Health Alert: Wound Botulism Associated with Black Tar Heroin. September 30, 2022. 9-30-22.pdf (
  3. Peak CM, Rosen H, Kamali A, et al. Wound Botulism Outbreak Among Persons Who Use Black Tar Heroin – San Diego County, California, 2017-2018. MMWR 2019;67:1415-1418.