Cholera Treatment & Management

emedicine.medscape.com /article/962643-treatment

Sections

Treatment

Approach Considerations
Rehydration is the first priority in the treatment of cholera. Rehydration is accomplished in 2 phases: rehydration
and maintenance.

The goal of the rehydration phase is to restore normal hydration status, which should take no more than 4 hours.
Set the rate of intravenous infusion in severely dehydrated patients at 50-100 mL/kg/hr. Lactated Ringer solution
is preferred over isotonic sodium chloride solution because saline does not correct metabolic acidosis

The goal of the maintenance phase is to maintain normal hydration status by replacing ongoing losses. The oral
route is preferred, and the use of oral rehydration solution (ORS) at a rate of 500-1000 mL/hr is recommended.

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Treatment Guidelines
The World Health Organization (WHO) guidelines for the management of cholera are practical, easily
understood, and readily applied in clinical practice (see Table 7). These guidelines can be used for the treatment
of any patient with diarrhea and dehydration. Diagnosis of cholera is not required to initiate hydration therapy.

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Cholera Cots
In areas where cholera is endemic, cholera cots have been used to assess the volume of ongoing stool losses. A
cholera cot is a cot covered by a plastic sheet with a hole in the center to allow the stool to collect in a calibrated
bucket underneath.

Use of such a cot allows minimally trained health workers to calculate fluid losses and replacement needs. The
volume of stool is measured every 2-4 hours, and the volume of fluid administered is adjusted accordingly.

In the initial phase of therapy, urine losses account for only a small proportion of fluid losses, and the amount of
fluid in the bucket is an adequate reflection of stool losses. With rehydration, urine should be collected
separately, so that a vicious circle of increasing urine output and overhydration can be avoided.

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Rehydration

The WHO has provided recommendations for fluid replacement in patients with dehydration [16] (see Table 2).
The recommendations include recommendations for fluid replacement for severe hydration, some dehydration,
and no dehydration.

Severe dehydration
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Administer intravenous (IV) fluid immediately to replace fluid deficit. Use lactated Ringer solution or, if that is not
available, isotonic sodium chloride solution. If the patient can drink, begin giving oral rehydration salt solution
(ORS) by mouth while the drip is being set up; ORS can provide the potassium, bicarbonate, and glucose that
saline solution lacks.

For patients older than 1 year, give 100 mL/kg IV in 3 hours30 mL/kg as rapidly as possible (within 30 min)
then 70 mL/kg in the next 2 hours. For patients younger than 1 year, administer 100 mL/kg IV in 6 hours30
mL/kg in the first hour then 70 mL/kg in the next 5 hours.

Monitor the patient frequently. After the initial 30 mL/kg has been administered, the radial pulse should be strong
and blood pressure should be normal. If the pulse is not yet strong, continue to give IV fluid rapidly. Administer
ORS solution (about 5 mL/kg/h) as soon as the patient can drink, in addition to IV fluid.

Reassess the hydration status after 3 hours (infants after 6 h), using Table 1. In the rare case that the patient still
exhibits signs of severe dehydration, repeat the IV therapy already given. If signs of some dehydration are
present, continue as indicated below for some dehydration. If no signs of dehydration exist, maintain hydration
by replacing ongoing fluid losses.

Routes for parenteral rehydration

Accessing a peripheral vein is relatively easy, despite the severe dehydration. If a peripheral vein is not readily
accessible, scalp veins have been used for initial rehydration. As the vascular volume is reestablished, a larger
needle or catheter can be introduced in a peripheral vein.

Intraosseous routes have been used successfully in young children when veins cannot be accessed. The
intraperitoneal route has been tried, but is not recommended.

ORS solution can be administered via nasogastric tube if the patient has some signs of dehydration and cannot
drink or if the patient has severe dehydration and IV therapy is not possible at the treatment facility.

Overhydration

A risk of overhydration exists with intravenous fluids; it usually first manifests as puffiness around the eyes.
Continued excessive administration of intravenous fluids can lead to pulmonary edema and has been observed
even in children with normal cardiovascular reserve. Thus, it is important to monitor patients who are receiving
intravenous rehydration hourly. Serum-specific gravity is an additional measure of the adequacy of rehydration.

Some dehydration

Administer ORS solution according to the amount recommended in Table 3. WHO ORS contains the following:

Sodium 75 mmol/L

Chloride 65 mmol/L

Potassium 20 mmol/L

Bicarbonate 30 mmol/L

Glucose 111 mmol/L

A homemade equivalent is 6 teaspoons of sugar and one half teaspoon of salt in a liter of water; a half cup of
orange juice or some mashed banana can provide potassium. [17]

Use the patient's age only when weight is unknown. The approximate amount of ORS required (in mL) also can
be calculated by multiplying the patient's weight (in kg) times 75.

If the patient passes watery stools or wants more ORS solution than shown, give more. Monitor the patient
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frequently to ensure that the ORS solution is taken satisfactorily and to identify patients with profuse ongoing
diarrhea who require closer monitoring.

Reassess the patient after 4 hours, using Table 1. In the rare case where signs of severe dehydration have
appeared, rehydrate for severe dehydration, as above. If some dehydration is still present, repeat the
procedures for some dehydration and start to offer food and other fluids. If no signs of dehydration are present,
maintain hydration by replacing ongoing fluid losses.

Most patients absorb enough ORS solution to achieve rehydration, even when they are vomiting. Vomiting
usually subsides within 2-3 hours, as rehydration is achieved.

Urine output decreases as dehydration develops and may cease. It usually resumes within 6-8 hours after
starting rehydration. Regular urinary output (ie, every 3-4 h) is a good sign that enough fluid is being given.

No signs of dehydration

Patients who have no signs of dehydration when first observed can be treated at home. Give these patients ORS
packets to take home, enough for 2 days. Demonstrate how to prepare and give the solution. The caretaker
should give the patient the amount of ORS solution shown in Table 4.

Instruct the patient or the caretaker to return if any of the following signs develop:

Increased number of watery stools

Eating or drinking poorly

Marked thirst

Repeated vomiting

Any signs indicating other problems (eg, fever, blood in stool)

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Maintenance of Hydration
Maintain hydration of patients presenting with severe or some dehydration. Replace ongoing fluid losses until
diarrhea stops.

When a patient who has been rehydrated with IV fluid or ORS solution is reassessed and has no signs of
dehydration, continue to administer ORS solution to maintain normal hydration. The aim is to replace stool
losses as they occur with an equivalent amount of ORS solution. See Table 5 .

The amount of ORS solution required to maintain hydration varies greatly among patients, depending on the
volume of stool passed. It is highest in the first 24 hours of treatment and is especially large in patients who
present with severe dehydration. In the first 24 hours, the average requirement of ORS solution in such patients
is 200 mL/kg, but some patients may need as much as 350 mL/kg.

Continue to reassess the patient for signs of dehydration at least every 4 hours to ensure that enough ORS
solution is being taken. Patients with profuse ongoing diarrhea require more frequent monitoring. If signs of
some dehydration are detected, the patient should be rehydrated as described earlier, before continuing with
treatment to maintain hydration.

A few patients, whose ongoing stool output is very large, may have difficulty in drinking the volume of ORS
needed to maintain hydration. If these patients become tired, vomit frequently, or develop abdominal distension,
ORS solution should be stopped and hydration should be maintained intravenously with lactated Ringer solution
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or isotonic sodium chloride solution, administering 50 mL/kg in 3 hours. After this is done, resuming treatment
with ORS solution is usually possible.

Keep the patient under observation, if possible, until diarrhea stops or is infrequent and of small volume. This is
especially important for any patient presenting with severe dehydration. If a patient must be discharged from the
hospital before diarrhea has stopped, show the caretaker how to prepare and give ORS solution, and instruct the
caretaker to continue to give ORS solution, as above. Also instruct the caretaker to return the patient to the
hospital if any signs of danger appear.

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Antibiotic Treatment
An effective antibiotic can reduce the volume of diarrhea in patients with severe cholera and shorten the period
during which V cholerae O1 is excreted. In addition, it usually stops the diarrhea within 48 hours, thus shortening
the period of hospitalization. Whenever possible, antibiotic therapy should be guided by susceptibility reports.

Antibiotic treatment is indicated for severely dehydrated patients who are older than 2 years. Begin antibiotic
therapy after the patient has been rehydrated (usually in 4-6 h) and vomiting has stopped. No advantage exists
to using injectable antibiotics, which are expensive. No other drugs should be used in the treatment of cholera.
Antimicrobial agents typically are administered for 3-5 days (see Table 6). However, single-dose therapy with
tetracycline, doxycycline, furazolidone, or ciprofloxacin has been shown effective in reducing the duration and
volume of diarrhea. Because single dose doxycycline has been shown to be as effective as multiple doses of
tetracycline, this has become the preferred regimen.

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Fluid Replacement for Dehydration

Table 2. Fluid Replacement for Dehydration (Open Table in a new window)

Severe Intravenous (IV) drips of Ringer Lactate or, if not available,

dehydration normal saline and oral rehydration salts as outlined below 100 mL/kg in 3-h period
(in 6 h for children < 1 y)

Start rapidly (30 mL/kg

within 30 min, then slow
down)

Total amount for first 24

h: 200 L/kg

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 Some Oral rehydration salts (amount in first 4 h)
dehydration Infants < 4 mo (< 5 kg):
200400 mL

Infants 411 mo (57.9

kg): 400600 mL

Children 12 y (810.9
kg): 600800 mL

Children 24 y (1115.9
kg): 8001200 mL

Children 514 y (16

29.9 kg): 12002200 mL

Patients >14 y (30 kg):

22004000 mL

No Oral rehydration salts

dehydration Children < 2 y: 50100
mL, up to 500 mL/day

Children 29 y: 100200
mL, up to 1000 mL/day

Patients >9 y: As much

as wanted, up to 2000
mL/day

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Oral Rehydration During First 4 Hours

Table 3. Approximate Amount of Oral Rehydration Solution to Administer in the First 4 Hours (Open Table in a
new window)

Age < 4 mo 4-11 mo 12-23 mo 2-4 y 5-14 y 15 y

Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg

ORS solution in mL 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

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Oral Rehydration for Home Administration

Table 4. Estimate of Oral Rehydration Solution Packets to Be Administered at Home (Open Table in a new
window)

Age Amount of Solution After Each Loose Stool ORS Packets Needed

< 24 mo 50-100 mL Enough for 500 mL/d

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 2-9 y 100-200 mL Enough for 1000 mL/d

10 y As much as is wanted Enough for 200 mL/d

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Oral Replacement Solution for Hydration Maintenance

Table 5. Oral Replacement Solution for Maintenance of Hydration (Open Table in a new window)

Age Amount of Solution After Each Loose Stool

< 24 mo 100 mL

2-9 y 200 mL

10 y As much as is wanted

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Antimicrobial Therapy for Cholera

Table 6. Antimicrobial Therapy Used in the Treatment of Cholera* (Open Table in a new window)

Antibiotic Single Multiple Dose (PO)

Dose
(PO)

Doxycycline 7 mg/kg; 2 mg/kg bid on day 1; then 2

not to mg/kg qd on days 2 and 3; not
exceed to exceed 100 mg/dose
300
mg/dose

Tetracycline 25 mg/kg; 40 mg/kg/d divided qid for 3 d;

not to not to exceed 2 g/d
exceed 1
g/dose

Furazolidone 7 mg/kg; 5 mg/kg/d divided qid for 3 d;

not to not to exceed 400 mg/d
exceed
300
mg/dose

Trimethoprim and sulfamethoxazole Not < 2 months: Contraindicated

evaluated
2 months: 5-10 mg/kg/d
(based on trimethoprim
component) divided bid for 3
d; not to exceed 320 mg/d
trimethoprim and 1.6 g/d of
sulfamethoxazole

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 Ciprofloxacin 30 mg/kg; 30 mg/kg/d divided q12h for 3
not to d; not to exceed 2 g/d
exceed 1
g/dose

Ampicillin Not 50 mg/kg/d divided qid for 3 d;

evaluated not to exceed 2 g/d

Erythromycin Not 40 mg/kg/d erythromycin

evaluated base divided tid for 3 d; not to
exceed 1 g/d

* Antimicrobial therapy is an adjunct to fluid therapy of cholera and

is not an essential component. However, it reduces diarrhea
volume and duration by approximately 50%. The choice of
antibiotics is determined by the susceptibility patterns of the local
strains of V cholerae O1 or O139.
Tetracycline and doxycycline can discolor permanent teeth of
children younger than 8 years. However, the risk is small when
these drugs are used for short courses of therapy, especially if
used in a single dose.

Single-dose therapy of these drugs has not been evaluated

systematically in children, and recommendations are extrapolated
from experience in adults.
Fluoroquinolones (eg, ciprofloxacin) are not approved in the
United States for use in persons younger than 18 years. When
given in high doses to juvenile animals, they cause arthropathy.
Clinical experience indicates that this risk is very small in children
when used for short courses of therapy.

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WHO Guidelines for Cholera Management

Table 7. WHO Guidelines for Cholera Management (Open Table in a new window)

Steps in the treatment of a patient with suspected cholera are as follows:

1. Assess for dehydration (see Table 1)

2. Rehydrate the patient and monitor frequently, then reassess hydration status

3. Maintain hydration; replace ongoing fluid losses until diarrhea stops

4. Administer an oral antibiotic to the patient with severe dehydration

5. Feed the patient

More detailed guidelines for the treatment of cholera are as follows:

Evaluate the degree of dehydration upon arrival

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 Rehydrate the patient in 2 phases; these include rehydration (for 2-4 h) and maintenance (until diarrhea
abates)

Register output and intake volumes on predesigned charts and periodically review these data

Use the intravenous route only (1) during the rehydration phase for severely dehydrated patients for
whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not
tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers
(ie, >10 mL/kg/h)

During the maintenance phase, use oral rehydration solution at a rate of 800-1000 mL/h; match
ongoing losses with ORS administration

Discharge patients to the treatment center if oral tolerance is greater than or equal to 1000 mL/h, urine
volume is greater than or equal to 40 mL/h, and stool volume is less than or equal to 400 mL/h.

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Diet
Resume feeding with a normal diet when vomiting has stopped. Continue breastfeeding infants and young
children.

Malnutrition after infection is not a major problem, as it is after infection with Shigella species or rotavirus
diarrhea. The catabolic cost of the infection is relatively low, anorexia is neither profound nor persistent, and
intestinal enzyme activity remains intact after infection; hence, intestinal absorption of nutrients is near normal.

There is no reason to withhold food from cholera patients.

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Deterrence/Prevention
The current response to cholera outbreaks tends to be reactive, in the form of an emergency response. Although
this approach prevents many deaths, it fails to prevent cases of cholera.

Rapid identification of cases in children and adults and prompt treatment will limit further spread of the disease.
Water can be made safer to drink by boiling or adding chlorine, although both methods are expensive and
difficult to implement during epidemics.

Sensitive surveillance and prompt reporting contribute to the rapid containment of cholera epidemics. In many
endemic countries, cholera is a seasonal disease, occurring every year usually during the rainy season.
Surveillance systems can provide an early alert to outbreaks, which should lead to a coordinated response and
assist in the preparation of preparedness plans.

A multisectoral and coordinated approach is paramount to efficiently control a cholera outbreak. Key sectors to

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be involved are health, water and sanitation, fishery and agriculture, and education.

Cholera is usually transmitted through fecally contaminated water or food. Outbreaks can occur sporadically in
any part of the world where water supply, sanitation, food safety, and hygiene are inadequate. WHO
recommends improvements in water supply and sanitation as the most sustainable approach for protecting
against cholera and other waterborne epidemic diarrheal diseases. However, such an approach is unrealistic for
the many impoverished populations most affected by cholera.

Outbreaks can be mitigated and case-fatality rates can be reduced by means of several other measures, many
of which are suitable for community participation. Human behaviors related to personal hygiene and food
preparation contribute greatly to the occurrence and severity of outbreaks. Education on specific hygiene
practices is important in the prevention of cholera.

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Vaccines
Difficulties in implementing public health and personal preventive practices have stimulated the century-long
search for vaccines. Experience with the parenteral vaccine has been disappointing. Because of a better
understanding of the immune response to natural infection, researchers now know that the oral route of
administration is better.

Cholera vaccination is no longer officially required for any international traveler, and the International Certificate
of Vaccination no longer provides a special section for recording cholera immunization. The risk of an
international traveler from a developed country contracting cholera is small (1 case in 500,000 travelers).

WHO has identified 3 oral vaccines. These are available in some countries but are used mainly by travelers.

One vaccine consists of a monovalent killed whole-cell V cholerae O1 with purified recombinant B-subunit of
cholera toxoid (WC/rBS). Clinical trials have been performed in Bangladesh, Peru, and Sweden. Efficacy trials
have shown that this vaccine is safe and confers 85-90% protection during 6 months in all age groups after
administration of 2 doses, 1 week apart. In Bangladesh, protection declined rapidly after 6 months in young
children but was still about 60% in older children and adults after 2 years.

This vaccine is available in more than 60 countries for adults and children older than 2 years. It was approved
for use in the United States in 2006.

Shanchol and ORCVAX are bivalent vaccines that are based on serogroups O1 and O139; however, they do not
contain the bacterial toxin B subunit. ORCVAX was originally formulated in Vietnam in 1997 and was modified in
2004. Over 20 million doses have been administered to adults and children in endemic areas of Vietnam.
Shanchol is a similar formulation available in India. Shanchol is administered in 2 liquid doses 14 days apart in
adults and children older than 1 year. A booster dose is recommended after 2 years. [18]

CVD 103-HgR is a cholera vaccine developed by the Swiss Serum and Vaccine Institute in Berne, Switzerland.
This vaccine, although not recognized by the WHO, is available in Europe, Latin America, and, since 1997,
Canada. The vaccine is composed of attenuated V cholerae O1 prepared by recombinant DNA. It has been
tested in industrialized countries and in developing countries that have endemic, epidemic, and little or no
cholera. [19]

The vaccine is highly protective against moderate and severe cholera, and it is very well tolerated and extremely
immunogenic. In addition, the rate and extent of vaccine excretion is minimal.

In June, 2016, the FDA approved the CVD 103-HgR cholera vaccine ( Vaxchora, PaxVax, Inc) for the prevention
of cholera caused by serogroup 01. Also, in June, 2016 the Advisory Committee on Immunization Practices

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(ACIP) of the CDC voted unanimously to recommend the CVD 103-HgR cholera vaccine (Vaxchora, PaxVax,
Inc) for adults aged 18 to 64 years who are traveling to an area of active toxigenic Vibrio cholerae O1
transmission and who have an increased risk for exposure or poor clinical outcome if infected. [20, 21]

According to a 2011 Cochrane review on oral cholera vaccines, currently available vaccines are safe and provide
50-60% efficacy in preventing episodes of cholera in the first 2 years after the primary vaccination schedule. A
booster dose may be required after 3 years. [22] At this time, no countries use these vaccines in routine
immunization.

A study by Qadri et al assessed the feasibility and protective effect of delivering the vaccine Shanchol through
routine government services in urban Bangladesh and evaluated the benefit of adding behavioral interventions
to encourage safe drinking water and hand washing along with the vaccination. The study analyzed 267,270
people, 94,675 assigned to vaccination only, 92,539 assigned to vaccination and behavioral change, and 80,056
assigned to non-intervention. The study found that vaccine coverage was 65% in the vaccination only group and
66% in the vaccination and behavioral change group. Overall protective effectiveness was 37% in the
vaccination group and 45% in the vaccination and behavioral change group. [23, 24]

A study by Matias et al found that immunization with the bivalent oral cholera vaccine (Shanchol) induced
antibody secreting cell responses among a cohort of healthy adults in Haiti after a single dose, however, the
second dose of vaccine resulted in a minimal response. [25]

A study by Azman et al reported that vaccination campaigns that use a single dose of oral cholera vaccine may
be able to prevent more deaths than the standard two-dose campaign when vaccine supplies are limited. [26, 27]

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Medication

References

1. Centers for Disease Control and Prevention. Cholera. Available at http://www.cdc.gov/cholera/index.html.

Accessed: July 7, 2011.

2. CDC. 150th anniversary of John Snow and the pump handle. Centers for Disease Control and
Prevention. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5334a1.htm. Accessed: March
29, 2006.

3. Kenneth Todar. Todar's Online Textbook of Bacteriology. Available at

http://textbookofbacteriology.net/cholera.html. Accessed: April 12, 2010.

4. Sack D, Cadoz M. Cholera vaccines. Plotkin SA, Orenstein WA. Vaccines. Philadelphia: WB Saunders
Company; 1999. 639-649.

5. Steinberg EB, Greene KD, Bopp CA, Cameron DN, Wells JG, Mintz ED. Cholera in the United States,
1995-2000: trends at the end of the twentieth century. J Infect Dis. 2001 Sep 15. 184(6):799-802.
[Medline].

6. Tobin-D'Angelo M, Smith AR, Bulens SN, et al. Severe diarrhea caused by cholera toxin-producing vibrio
cholerae serogroup O75 infections acquired in the southeastern United States. Clin Infect Dis. 2008 Oct
15. 47(8):1035-40. [Medline].

7. CDC. Two cases of toxigenic Vibrio cholerae O1 infection after Hurricanes Katrina and Rita--Louisiana,
October 2005. MMWR Morb Mortal Wkly Rep. 2006 Jan 20. 55(2):31-2. [Medline].
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 8. WHO. Cholera vaccines: WHO position paper. World Health Organization. Available at
http://www.who.int/wer/2010/wer8513.pdf. Accessed: April 13th, 2010.

9. WHO. Cholera Country Profiles. World Health Organization. Available at

http://www.who.int/cholera/countries/en/index.html. Accessed: April 12th, 2009.

10. Luquero FJ, Grout L, Ciglenecki I, et al. First outbreak response using an oral cholera vaccine in Africa:
vaccine coverage, acceptability and surveillance of adverse events, Guinea, 2012. PLoS Negl Trop Dis.
2013 Oct 17. 7(10):e2465. [Medline]. [Full Text].

11. Gu W, Yin J, Yang J, et al. Characterization of Vibrio cholerae from 1986 to 2012 in Yunnan Province,
southwest China bordering Myanmar. Infect Genet Evol. 2013 Oct 28. [Medline].

12. Pan American Health Organization. EOC Situation Report - Cholera Outbreak #20. Pan American Health
Organization. Available at http://new.paho.org/blogs/haiti/?p=2034. Accessed: July 17th, 2011.

13. CDC journal study strongly suggests U.N. peacekeepers from Nepal imported cholera to Haiti.
Washington Post. June 29, 2011. [Full Text].

14. Barzilay EJ, Schaad N, Magloire R, et al. Cholera surveillance during the Haiti epidemic--the first 2 years.
N Engl J Med. 2013 Feb 14. 368(7):599-609. [Medline].

15. Chin CS, Sorenson J, Harris JB, et al. The origin of the Haitian cholera outbreak strain. N Engl J Med.
2011 Jan 6. 364(1):33-42. [Medline]. [Full Text].

16. CDC. 2010 Haiti Cholera Outbreak. Centers for Disease Control and Prevention. Available at
http://www.cdc.gov/haiticholera/diagnosistreatment.htm. Accessed: 10/29/2010.

17. Rehydration Project. Oral Rehydration Solutions: Made at Home. Available at

http://rehydrate.org/solutions/homemade-ors.pdf. Accessed: July 7, 2011.

18. WHO. Cholera vaccines: WHO position paper. Wkly Epidemiol Rec. 2010 Mar 26. 85(13):117-28.
[Medline].

19. Chen WH, Greenberg RN, Pasetti MF, et al. Safety and immunogenicity of single-dose live oral cholera
vaccine strain CVD 103-HgR prepared from new master and working cell banks. Clin Vaccine Immunol.
2013 Oct 30. [Medline].

20. Chen WH, Cohen MB, Kirkpatrick BD, Brady RC, Galloway D, Gurwith M, et al. Single-dose Live Oral
Cholera Vaccine CVD 103-HgR Protects Against Human Experimental Infection With Vibrio cholerae O1
El Tor. Clin Infect Dis. 2016 Jun 1. 62(11):1271-81. [Medline].

21. Brown T. ACIP Backs Cholera, MenACWY Vaccines. Medscape Medical News. Available at
http://www.medscape.com/viewarticle/865292. June 24, 2016; Accessed: June 27, 2016.

22. Sinclair D, Abba K, Zaman K, Qadri F, Graves PM. Oral vaccines for preventing cholera. Cochrane
Database Syst Rev. 2011 Mar 16. CD008603. [Medline].

23. Qadri F, Ali M, Chowdhury F, et al. Feasibility and effectiveness of oral cholera vaccine in an urban
endemic setting in Bangladesh: a cluster randomised open-label trial. Lancet. 2015 Oct 3. 386
(10001):1362-71. [Medline].

24. Barclay L. Oral Cholera Vaccine Safe, Effective in First Real-life Trial. Medscape Medical News. Available
at http://www.medscape.com/viewarticle/847690. July 09, 2015; Accessed: February 17, 2016.

25. Matias WR, Falkard B, Charles RC, Mayo-Smith LM, Teng JE, Xu P, et al. Antibody Secreting Cell
Responses following Vaccination with Bivalent Oral Cholera Vaccine among Haitian Adults. PLoS Negl
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 Trop Dis. 2016 Jun. 10 (6):e0004753. [Medline].

26. Azman AS, Luquero FJ, Ciglenecki I, Grais RF, Sack DA, Lessler J. The Impact of a One-Dose versus
Two-Dose Oral Cholera Vaccine Regimen in Outbreak Settings: A Modeling Study. PLoS Med. 2015 Aug.
12 (8):e1001867. [Medline].

27. Pullen LC. Cholera Vaccine: Reduction to Single Dose May Save Lives. Medscape Medical News.
Available at http://www.medscape.com/viewarticle/850078. August 26, 2015; Accessed: February 17,
2016.

Media Gallery

Electron microscopic image of Vibrio cholera.

Scanning electron microscope image of Vibrio cholerae bacteria, which infect the digestive system.

This scanning electron micrograph (SEM) depicts a number of Vibrio cholerae bacteria of the serogroup
01; magnified 22371x. Image courtesy of CDC/Janice Haney Carr.

This patient with cholera is drinking oral rehydration solution (ORS) in order to counteract the cholera-
induced dehydration. Image courtesy of the CDC.

of 4

Tables

Table 1. Assessment of the Patient With Diarrhea for Dehydration (based on WHO classification)

Sensorium Eyes Thirst Skin Pinch Decision

Abnormally Sunken Drinks poorly Goes back very If the patient has 2 or more of these signs,
sleepy or or not at all slowly (>2 sec) severe dehydration is present
lethargic

Restless, irritable Sunken Drinks Goes back slowly If the patient has 2 or
eagerly (< 2 sec)
more signs, some dehydration is present

Well, alert Normal Drinks Goes back Patient has no dehydration

normally, not quickly

thirsty

Table 2. Fluid Replacement for Dehydration

Severe Intravenous (IV) drips of Ringer Lactate or, if not available,

dehydration normal saline and oral rehydration salts as outlined below 100 mL/kg in 3-h period
(in 6 h for children < 1 y)

Start rapidly (30 mL/kg

within 30 min, then slow
down)

Total amount for first 24

h: 200 L/kg

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 Some Oral rehydration salts (amount in first 4 h)
dehydration Infants < 4 mo (< 5 kg):
200400 mL

Infants 411 mo (57.9

kg): 400600 mL

Children 12 y (810.9
kg): 600800 mL

Children 24 y (1115.9
kg): 8001200 mL

Children 514 y (16

29.9 kg): 12002200 mL

Patients >14 y (30 kg):

22004000 mL

No Oral rehydration salts

dehydration Children < 2 y: 50100
mL, up to 500 mL/day

Children 29 y: 100200
mL, up to 1000 mL/day

Patients >9 y: As much

as wanted, up to 2000
mL/day

Table 3. Approximate Amount of Oral Rehydration Solution to Administer in the First 4 Hours

Age < 4 mo 4-11 mo 12-23 mo 2-4 y 5-14 y 15 y

Weight < 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 kg 16-29.9 kg 30 kg

ORS solution in mL 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

Table 4. Estimate of Oral Rehydration Solution Packets to Be Administered at Home

Age Amount of Solution After Each Loose Stool ORS Packets Needed

< 24 mo 50-100 mL Enough for 500 mL/d

2-9 y 100-200 mL Enough for 1000 mL/d

10 y As much as is wanted Enough for 200 mL/d

Table 5. Oral Replacement Solution for Maintenance of Hydration

Age Amount of Solution After Each Loose Stool

< 24 mo 100 mL

2-9 y 200 mL

10 y As much as is wanted

Table 6. Antimicrobial Therapy Used in the Treatment of Cholera*

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Antibiotic Single Multiple Dose (PO)
Dose
(PO)

Doxycycline 7 mg/kg; 2 mg/kg bid on day 1; then 2

not to mg/kg qd on days 2 and 3; not
exceed to exceed 100 mg/dose
300
mg/dose

Tetracycline 25 mg/kg; 40 mg/kg/d divided qid for 3 d;

not to not to exceed 2 g/d
exceed 1
g/dose

Furazolidone 7 mg/kg; 5 mg/kg/d divided qid for 3 d;

not to not to exceed 400 mg/d
exceed
300
mg/dose

Trimethoprim and sulfamethoxazole Not < 2 months: Contraindicated

evaluated
2 months: 5-10 mg/kg/d
(based on trimethoprim
component) divided bid for 3
d; not to exceed 320 mg/d
trimethoprim and 1.6 g/d of
sulfamethoxazole

Ciprofloxacin 30 mg/kg; 30 mg/kg/d divided q12h for 3

not to d; not to exceed 2 g/d
exceed 1
g/dose

Ampicillin Not 50 mg/kg/d divided qid for 3 d;

evaluated not to exceed 2 g/d

Erythromycin Not 40 mg/kg/d erythromycin

evaluated base divided tid for 3 d; not to
exceed 1 g/d

* Antimicrobial therapy is an adjunct to fluid therapy of cholera and

is not an essential component. However, it reduces diarrhea
volume and duration by approximately 50%. The choice of
antibiotics is determined by the susceptibility patterns of the local
strains of V cholerae O1 or O139.
Tetracycline and doxycycline can discolor permanent teeth of
children younger than 8 years. However, the risk is small when
these drugs are used for short courses of therapy, especially if
used in a single dose.
Single-dose therapy of these drugs has not been evaluated
systematically in children, and recommendations are extrapolated
from experience in adults.

Fluoroquinolones (eg, ciprofloxacin) are not approved in the

United States for use in persons younger than 18 years. When
given in high doses to juvenile animals, they cause arthropathy.
Clinical experience indicates that this risk is very small in children
when used for short courses of therapy.

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Table 7. WHO Guidelines for Cholera Management

Steps in the treatment of a patient with suspected cholera are as follows:

1. Assess for dehydration (see Table 1)

2. Rehydrate the patient and monitor frequently, then reassess hydration status

3. Maintain hydration; replace ongoing fluid losses until diarrhea stops

4. Administer an oral antibiotic to the patient with severe dehydration

5. Feed the patient

More detailed guidelines for the treatment of cholera are as follows:

Evaluate the degree of dehydration upon arrival

Rehydrate the patient in 2 phases; these include rehydration (for 2-4 h) and maintenance (until diarrhea
abates)

Register output and intake volumes on predesigned charts and periodically review these data

Use the intravenous route only (1) during the rehydration phase for severely dehydrated patients for
whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not
tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers
(ie, >10 mL/kg/h)

During the maintenance phase, use oral rehydration solution at a rate of 800-1000 mL/h; match
ongoing losses with ORS administration

Discharge patients to the treatment center if oral tolerance is greater than or equal to 1000 mL/h, urine
volume is greater than or equal to 40 mL/h, and stool volume is less than or equal to 400 mL/h.

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Contributor Information and Disclosures

Author

Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI Director, Division of Hospital Medicine,
Department of Medicine, Rhode Island Hospital

Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI is a member of the following medical societies: Society of Hospital
Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Vidhu V Thaker, MBBCh, MD Attending Pediatrician, Haverstraw Pediatrics; Clinical Assistant Professor of

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Pediatrics, New York Medical College

Vidhu V Thaker, MBBCh, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics
Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases,
Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of
Science, American College of Physicians, American Federation for Medical Research, Association of
Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America , Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD Minnesota American Legion and Auxiliary Heart Research Foundation Chair of Pediatrics,
Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of
Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious
Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic
Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics,
American Association of Immunologists , American Pediatric Society, American Society for Microbiology,
Infectious Diseases Society of America , Louisiana State Medical Society, Pediatric Infectious Diseases Society,
Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the
Advancement of Science, American College of Physicians-American Society of Internal Medicine , American
Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious
Diseases Society of America, International Immunocompromised Host Society, International Society for
Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences , Pediatric
Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research,
Southern Medical Association , Society for Ear, Nose and Throat Advances in Children, American Federation for
Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

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