Cholera medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, MBBS [2]

## Overview

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In most cases, cholera can be successfully treated with oral rehydration therapy (ORT), which is highly effective, safe, and simple to administer. In severe cases with significant dehydration, intravenous rehydration may be necessary. Ringer's lactate is the preferred solution, often with added potassium. Large volumes and continued replacement until diarrhea has subsided may be needed[1][2]. Ten percent of a person's body weight in fluid may need to be given in the first two to four hours. Antibiotic treatments for one to three days shorten the course of the disease and reduce the severity of the symptoms[3]. People can recover even without them, if sufficient hydration and electrolyte balance is maintained. Doxycycline is typically used first line[4], although some strains of V. cholerae have shown resistance[5]. Zinc supplementation has been shown to reduce stool output and reduces the duration and severity of symptoms.[6]

## Medical Therapy

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### Summary of the Treatment

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* Rehydrate with ORS or IV solution depending on the severity. Rehydration involves replenishment of the lost fluids and then maintenance of the fluid balance [1][2]
* Maintain hydration and monitor frequently the hydration status[1][2]
* Give antibiotics for severe cholera cases[7]
* Zinc supplementation for reduction of stool output and improvement of symptom duration and severity[6]

### Management of Cholera Patients (table 1)

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Mental status  | Eyes  | Thirst  | Skin pinch  | Conclusions  | Management

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Normal, Alert  | Normal, hydrated  | Normal  | Goes down quickly (spontaneously)  | No / Mild dehydration |

* Child < 2 years: 50–100 ml (1/4–1/2 cup)ORS solution. Up to approximately 1/2 liter a day.
* Child between 2 and 9 years: 100–200 ml. Up to approximately 1 liter a day.
* Patient of 10 years of age or more as much as wanted, up to approximately 2 liters a day.

Irritable  | Sunken  | Drink eagerly  | Goes back slowly (< 2 sec)  | Some / Moderate dehydration (in case if 2 of the symptoms are present)  |

* Give oral rehydration salt in the amount recommended in below in table 2
* Nasogastric tubes can be used for re-hydration when ORS solution increases vomiting and nausea or when the patient cannot drink
* Monitor the patient frequently

Lethargic, unconscious or floppy  | Sunken, absence of tears  | Drinks poorly  | Goes back slowly (> 2 sec)  | Severe dehydration (in case if 2 of the symptoms are present)  |

* Put an IV drip to start intravenous rehydration
* In case this is not possible, rehydrate with ORS
* Give IV drips of Ringer's lactate or if not available cholera saline (or normal saline)
* 100 ml/kg in three-hour period (in 6 hours for children aged less than 1 year)
* Start rapidly (30ml/kg within 30 min) and then slow down.

Total amount per day: 200 ml/kg during the first 24 hours

### Management of Patients with Moderate Dehydration (table 2)

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Age  | Less than 4 months  | 4–11 months  | 12–23 months  | 2–4 years  | 5–14 years  | 15 years

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Weight  | Less than 5 kgs  | 5–7.9 kg  | 8–10.9 kg  | 11–15.9 kg  | 16–29.9 kg  | 30 kg or more
ORS solution in ml  | 200–400  | 400–600  | 600–800  | 800–1200  | 1200–2200  | 2200–4000

### Maintenance of Hydration and Monitoring the Patient

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Reassess the patient for signs of dehydration regularly during the first six hours:

* Number and quantity of stools and vomit in order to compensate for the loss of body fluids
* Radial pulse: if it remains weak, IV rehydration must be continued.

### Method to Prepare Home-made Oral Rehydration Therapy Solution

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* If ORS sachets are available, dilute one sachet in one litre of safe water
* Otherwise: Add to one litre of safe water:
* Salt 1/2 small spoon (2.5 grams)
* Sugar 6 small spoons (30 grams)
* Try to compensate for loss of potassium (for example, eat bananas or drink green coconut water)

## Antibiotic regimen

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* 1\. WHO [8] [9]

* Note: Antibiotic treatment for cholera patients with severe dehydration only
* Adults

* Preferred regimen: Doxycycline 300 mg po single dose
* Alternative regimen: Tetracycline 12.5 mg/kg PO qid for 3 days

* Pediatric

* Under 12 years old

* Preferred regimen: Erythromycin 12.5 mg/kg PO qid for 3 days

* Over 12 years old

* Preferred regimen: Doxycycline 300 mg po single dose
* Alternative regimen: Tetracycline 12.5 mg/kg PO qid for 3 days

* 2\. Pan American Health Organization [10]

* Note: Antibiotic treatment for cholera patients with moderate or severe dehydration
* 2.1 Adult

* Preferred regimen: Doxycycline 300 mg po single dose
* Alternative regimen (1): Ciprofloxacin 1 g PO single dose
* Alternative regimen (2): Azithromycin 1 g PO single dose

* 2.2 Pediatric

* 2.2.1 Children over 3 year, who can swallow tablets

* Preferred regimen (1): Erythromycin 12.5 mg/kg/ PO qid for 3 days
* Preferred regimen (2): Azithromycin 20 mg/kg PO in a single dose
* Alternative regimen (1): Ciprofloxacin suspension or tablets 20 mg/kg PO single dose
* Alternative regimen (2): Doxycycline suspension or tablets 2-4 mg/kg PO single dose
* Note: Although doxycycline has been associated with a low risk of yellowing of the teeth in children, its benefits outweigh its risks

* 2.2.2 Children under 3 year, or infants who cannot swallow tablets

* Preferred regimen (1): Erythromycin suspension 12.5 mg/kg/ PO qid for 3 days
* Preferred regimen (2): Azithromycin suspension 20 mg/kg PO single dose
* Alternative regimen (1): Ciprofloxacin suspension 20 mg/kg PO single dose
* Alternative regimen (2): Doxycycline syrup 2-4 mg/kg PO single dose

* 2.3 Pregnancy

* Preferred regimen (!): Erythromycin 500 mg/ PO qid for 3 days
* Preferred regimen (2): Azithromycin 1 g PO single dose

### Nutrition

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* Proper attention to nutrition is particularly important, as patients with cholera often ignore nutrition due to diarrhea and vomiting. This may lead to hypoglycemia and associated complications like seizure, coma, and even death in the pediatric population.
* Provide frequent small meals with familiar foods during the first two days rather than infrequent large meals.
* Breastfeeding of infants and young children should continue.

## References

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1. ↑ 1.0 1.1 1.2 Lankarani KB, Alavian SM (2013). "Lessons learned from past cholera epidemics, interventions which are needed today". J Res Med Sci. 18 (8): 630–1. PMC 3872598. PMID 24379835.
2. ↑ 2.0 2.1 2.2 Hahn S, Kim S, Garner P (2002). "Reduced osmolarity oral rehydration solution for treating dehydration caused by acute diarrhoea in children". Cochrane Database Syst Rev (1): CD002847. doi:10.1002/14651858.CD002847. PMID 11869639.CS1 maint: Multiple names: authors list (link)
3. ↑ Kabir I, Khan WA, Haider R, Mitra AK, Alam AN (1996). "Erythromycin and trimethoprim-sulphamethoxazole in the treatment of cholera in children". J Diarrhoeal Dis Res. 14 (4): 243–7. PMID 9203786.CS1 maint: Multiple names: authors list (link)
4. ↑ Sack DA, Islam S, Rabbani H, Islam A (1978). "Single-dose doxycycline for cholera". Antimicrob Agents Chemother. 14 (3): 462–4. PMC 352482. PMID 708024.CS1 maint: Multiple names: authors list (link)
5. ↑ Towner KJ, Pearson NJ, Mhalu FS, O'Grady F (1980). "Resistance to antimicrobial agents of Vibrio cholerae E1 Tor strains isolated during the fourth cholera epidemic in the United Republic of Tanzania". Bull World Health Organ. 58 (5): 747–51. PMC 2395989. PMID 6975183.CS1 maint: Multiple names: authors list (link)
6. ↑ 6.0 6.1 Roy SK, Hossain MJ, Khatun W, Chakraborty B, Chowdhury S, Begum A; et al. (2008). "Zinc supplementation in children with cholera in Bangladesh: randomised controlled trial". BMJ. 336 (7638): 266–8. doi:10.1136/bmj.39416.646250.AE. PMC 2223005. PMID 18184631.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
7. ↑ Nelson EJ, Nelson DS, Salam MA, Sack DA (2011). "Antibiotics for both moderate and severe cholera". N Engl J Med. 364 (1): 5–7. doi:10.1056/NEJMp1013771. PMID 21142691.CS1 maint: Multiple names: authors list (link)
8. ↑ "WHO. Cholera Outbreak: Assessing the Outbreak Response and Improving Preparedness" (PDF).
9. ↑ "Prevention and control of cholera outbreaks: WHO policy and recommendations".
10. ↑ [file:///Users/censhanshan/Desktop/cholera_clin_management_ENG_rev_JUN 1.pdf "PAHO. Recommendations for clinical management of cholera"] Check `|url=` value (help) (PDF).

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