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

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. 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. People can recover even without them, if sufficient hydration and electrolyte balance is maintained. Doxycycline is typically used first line, although some strains of V. cholerae have shown resistance. Zinc supplementation has been shown to reduce stool output and reduces the duration and severity of symptoms.

Medical Therapy

Summary of the Treatment

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

Management of Cholera Patients (table 1)

Mental status	Eyes	Thirst	Skin pinch	Conclusions	Management
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)

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

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

• 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

• 1. WHO

• 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

• 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

• 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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