The mainstay of therapy is supportive. Severe morbidity and death due to botulism is mostly attributable to aspiration or to respiratory failure. Close monitoring of cough and gag reflexes, assessment of oropharyngeal secretions, respiratory mechanics, and oxygenation is necessary. Mechanical ventilation should be strongly considered if the vital capacity falls below 15 ml/kg or negative inspiratory force measures less than 20 cm of water. Placement of a nasogastric tube to prevent aspiration and to permit nutrition in the setting of bulbar palsy often becomes necessary. When treating secondary infections, aminoglycosides and clindamycin should be avoided as they may exacerbate the existing neuromuscular blockade [78, 89] .