What is cholera?

From the Guidelines

Cholera treatment should prioritize aggressive oral or intravenous rehydration therapy to replace lost fluids and electrolytes, and for moderate to severe cases, antibiotics such as azithromycin (1g single dose for adults; 20mg/kg for children) can shorten the duration of illness, as recommended by the most recent guidelines 1.

Treatment Overview

The main goal of cholera treatment is to maintain a case fatality rate (CFR) of less than 1% 1. Treatment primarily involves:

• Aggressive oral or intravenous rehydration therapy to replace lost fluids and electrolytes
• Antibiotics for moderate to severe cases, with azithromycin being the preferred first-line therapy for children 1
• Zinc supplementation (20mg daily for 10-14 days) is recommended for children 1

Antibiotic Therapy

For moderate to severe cases, antibiotics can shorten the duration of illness. The recommended antibiotics are:

• Azithromycin (1g single dose for adults; 20mg/kg for children) 1
• Doxycycline (300mg single dose for adults) 1

Prevention Measures

Prevention measures include:

• Drinking safe water (boiled, treated with chlorine tablets, or properly filtered)
• Practicing good hygiene (handwashing with soap)
• Consuming thoroughly cooked food
• Avoiding raw seafood in endemic areas
• Cholera vaccines (Dukoral, Shanchol, Euvichol) provide short-term protection and are recommended for travelers to high-risk areas

Disease Transmission

The disease spreads through the fecal-oral route when people consume food or water contaminated with the bacteria. Without prompt treatment, cholera can cause severe dehydration and death within hours, but with proper rehydration therapy, the mortality rate drops below 1% 1.

From the Research

Definition and Treatment of Cholera

• Cholera is a dramatic clinical illness that requires rapid diagnosis and aggressive therapy, with clinical signs and symptoms of mild, moderate, and severe dehydration determined before beginning fluid therapy 2.
• The treatment of cholera involves fluid therapy with two phases: rehydration and maintenance, with the route and speed of fluid administration depending on the degree of dehydration 2.

Oral Rehydration Solution (ORS)

• ORS is used to treat dehydration caused by diarrheal diseases, including cholera, with formulations of ≤ 270 mOsm/L considered safe and effective for non-cholera diarrhea 3.
• For cholera, ORS ≤ 270 is associated with biochemical hyponatraemia, but there are no differences in terms of other outcomes compared to ORS ≥ 310 3.
• The World Health Organization recommends the use of ORS of 'reduced osmolarity' for acute non-cholera diarrhea and rice-based ORS for cholera diarrhea 4.

Severe Cholera Treatment

• Severe cholera is a life-threatening illness that requires emergency life-saving therapy with i.v. saline, optionally supplemented with potassium and alkali to correct fluid deficit, potassium losses, and acidosis 5.
• After initial rehydration, ongoing stool losses are replaced with ORS, which contains sodium chloride, potassium, and alkali, along with glucose or rice powder as a source of glucose 5.
• Antibiotics are given to reduce fluid requirements, and close monitoring of intake, outputs, and hydration status is performed for all patients 2, 6.

Case Management and Prevention

• Cholera can be effectively managed with oral rehydration solution alone in the majority of cases, with up to one-third of patients presenting with severe dehydration requiring rapid intravenous rehydration 6.
• Antibiotics reduce the duration of illness and should be used in patients with severe dehydration, with local sensitivities guiding the choice of antibiotic 6.
• Effective case management with strict attention to detail, including infection control and protocolized approaches, can reduce mortality to around 1% even in resource-poor settings 6.