Clinical predictors of respiratory failure and long-term outcome in black tar heroin-associated wound botulism

Study objectives: To our knowledge, the predictors of respiratory failure ( RF) and long-term mechanical ventilation have not previously been examined in patients with wound botulism associated with black tar heroin use. Design: Retrospective case series. Setting: A large university hospital. Patients: Twenty, consecutive patients from 1991 to 1998 with a diagnosis o f wound botulism associated with drug use as identified through chart recor ds from a single institution. Results: The predominant mode of drug use was subcutaneous (75%). Fifteen o f 20 patients (75%) developed RF. The clinical presentation was similar in groups with RF and without RF. Of those patients who received antitoxin wit hin 12 h of presentation, 57% required mechanical ventilation compared to 8 5% of patients receiving the antitoxin after 12 h. The median durations of mechanical ventilation were I I days for those who received antitoxin, with in 12 h, and 54 days for those who did not receive antitoxin within 12 h. T he duration of mechanical ventilation for patients receiving antibiotics wi thin 12 h was 35 days vs 54 days for patients receiving antibiotics after 1 2 h. Early tracheostomy (< 10 days after initial intubation) was associated with a shorter duration of mechanical ventilation (median, 45 days vs 60 d ays, respectively). Conclusion: Early antitoxin administration may decrease the need for and du ration of mechanical ventilation among patients with wound botulism. Early tracheostomy may be beneficial for patients with RF.