What is the treatment and prevention for cholera?

Cholera: Treatment and Prevention

Treatment Approach

The cornerstone of cholera treatment is aggressive oral rehydration solution (ORS) for most patients, with intravenous fluids reserved for severe dehydration, combined with oral antibiotics to reduce disease duration and transmission—this approach achieves case-fatality rates below 1%. 1

Rehydration Therapy (Primary Treatment)

Most cholera patients can be successfully treated with ORS alone, which contains sodium 90 mmol/L, potassium 20 mmol/L, chloride 80 mmol/L, base 30 mmol/L, and glucose 111 mmol/L (2%). 1

For Mild to Moderate Dehydration:

• Administer ORS orally to replace existing fluid deficits during the rehydration phase (first 3-4 hours), then continue with maintenance therapy to match ongoing stool losses. 1, 2
• ORS works through glucose-sodium cotransport at the intestinal brush border, which remains intact even during severe cholera, allowing net absorption of sodium and water despite ongoing secretory diarrhea. 1
• Provide additional plain drinking water at bedside to allow excretion of excess salt intake and prevent hypernatremia. 1

For Severe Dehydration (≥10% fluid deficit):

• Initiate intravenous Ringer's lactate immediately for patients presenting with shock, altered mental status, or inability to tolerate oral fluids. 1, 2
• Administer IV fluids rapidly to correct shock, with careful monitoring to prevent fluid overload, particularly in children. 1
• Transition to ORS once the patient is stabilized (pulse, perfusion, and mental status normalized) to replace ongoing losses. 1

Common pitfall: Overhydration can lead to hyponatremia and polyuria—match ORS intake to stool output rather than giving excessive volumes. 3

Antibiotic Therapy (Adjunctive Treatment)

Antibiotics reduce stool volume, shorten illness duration, and decrease vibrio excretion, thereby reducing transmission. 1, 4

First-Line Antibiotic:

• Doxycycline is the preferred agent: 300 mg single dose for adults; 6 mg/kg/day for children <15 years. 1, 5
• Doxycycline is FDA-approved for cholera caused by Vibrio cholerae and offers the advantage of single-dose therapy. 5

Alternative Antibiotics:

• Tetracycline for severely dehydrated patients (the most efficient transmitters): Adults 500 mg every 6 hours for 72 hours; Children 50 mg/kg/day divided every 6 hours for 72 hours. 1
• When tetracycline resistance is present, use furazolidone, erythromycin, or trimethoprim-sulfamethoxazole. 1
• Chloramphenicol can substitute for tetracycline at the same dosing schedule. 1

Important caveat: Antibiotic resistance is emerging globally, making local susceptibility testing valuable when resources permit. 6, 4

Nutritional Management

• Resume feeding as soon as appetite returns—there is no justification for "bowel rest" or fasting. 1
• Infants should continue breastfeeding throughout illness. 1
• Provide energy-rich, easily digestible foods to maintain nutritional status during and after illness. 1

Common pitfall: Delaying feeding prolongs recovery and worsens nutritional status unnecessarily. 1

Prevention Strategies

Primary Prevention Measures

Water supply safety is the most critical prevention intervention. 1

• Identify and eliminate contaminated water sources immediately during outbreaks. 1
• Develop alternative safe drinking water sources as an urgent priority. 1
• Implement water chlorination where feasible. 1

Sanitation and Hygiene

• Promote handwashing with soap, particularly after defecation and before food handling. 1
• Ensure proper food preparation and storage, as food can serve as a transmission vehicle. 1
• Prohibit food workers with diarrhea from working in feeding centers or food preparation areas. 1
• Healthcare workers must wash hands with soap after examining each cholera patient to prevent nosocomial transmission. 1

Outbreak Response

Early case-finding and aggressive community education prevent panic and reduce transmission. 1

• Establish easily accessible treatment centers stocked with ORS, IV fluids, and antibiotics. 1
• Implement active surveillance with daily reporting of new cases and deaths. 1
• Conduct epidemiologic investigations to identify transmission modes and risk factors. 1

Chemoprophylaxis and Vaccination

Mass chemoprophylaxis is NOT recommended—it diverts resources from more effective interventions (water, sanitation, treatment access). 1

• Single-dose doxycycline may be considered for immediate family members of diagnosed patients only in high-transmission settings (>15% attack rate) with adequate resources. 1

Currently available cholera vaccines are NOT recommended for outbreak control due to low efficacy, short protection duration, and resource diversion from proven interventions. 1

However, newer oral vaccines show promise for reducing antibiotic-resistant infections and may represent future effective control measures. 6

Surveillance

• Maintain standardized case definitions for cholera surveillance. 1
• Report any suspected cholera cases immediately, even before laboratory confirmation. 1
• Laboratory culture confirmation is necessary initially, with antibiotic sensitivity testing, but not required for every case once outbreak is confirmed. 1
• Monitor case-fatality rates closely—rates above 1% indicate inadequate treatment quality. 1