Treatment for Cholera
The cornerstone of cholera treatment is aggressive rehydration therapy with oral rehydration solution (ORS) for most patients, reserving intravenous fluids for severe dehydration, combined with oral antibiotics (doxycycline as first-line) to reduce stool volume and duration. 1
Immediate Assessment and Rehydration Strategy
Primary Goal
- Maintain case fatality rate below 1% through prompt and adequate fluid replacement 1
Rehydration Approach by Severity
Mild to Moderate Dehydration (Most Cases):
- Administer ORS solution orally as the primary treatment modality 1
- Most cholera patients can be successfully managed with ORS alone in outpatient settings 1
- The WHO-ORS formulation (containing sodium 90 mmol/L, potassium 20 mmol/L, chloride 80 mmol/L, base 30 mmol/L, and glucose 111 mmol/L) is effective for cholera despite being designed as a compromise solution 1
Severe Dehydration (≥10% fluid deficit):
- Initiate intravenous fluid therapy immediately for patients presenting with shock, altered mental status, or inability to tolerate oral fluids 1, 2
- Ringer's lactate is the preferred IV solution, though normal saline is acceptable 3
- Exercise careful supervision to prevent fluid overload, particularly in children receiving IV rehydration 1
- Transition to ORS once the patient is stabilized and can tolerate oral intake 2, 3
Fluid Volume Considerations
- Cholera produces more pronounced stool and electrolyte losses compared to other diarrheal diseases, requiring aggressive replacement 1, 4
- Adult patients may require approximately 7 liters of IV fluid followed by 14 liters of ORS over the treatment course 5
- Replace ongoing stool losses volume-for-volume with ORS to maintain electrolyte balance 1
Antibiotic Therapy
First-Line Treatment:
- Doxycycline is the preferred antibiotic when available 1, 6
- Antibiotics reduce both the volume and duration of diarrhea by approximately 50% 1, 7
- Doxycycline is FDA-approved for cholera caused by Vibrio cholerae 6
Alternative Antibiotics:
Tetracycline should be reserved for severely dehydrated patients who are the most efficient disease transmitters due to greater fecal losses 1
When tetracycline/chloramphenicol resistance is present: use furazolidone, erythromycin, or trimethoprim-sulfamethoxazole (TMP-SMX) 1
Chloramphenicol can substitute for tetracycline at the same dosing schedule 1
Clinical Rationale:
- Antibiotics are recommended for patients with moderate to severe dehydration 7
- Concurrent antibiotic administration accelerates the decline in purging rate 1, 4
- All antibiotics should be administered orally 1
Critical Monitoring and Pitfalls
Essential Monitoring
- Continuously assess hydration status, pulse, perfusion, and mental status 2, 3
- Track intake, output, and ongoing stool losses closely 3
- Monitor for signs of fluid overload, especially in pediatric patients receiving IV therapy 1
Common Pitfalls to Avoid
- Overhydration: Restrict ORS intake to match stool output rather than providing unlimited fluids, as overhydration can lead to hyponatremia and polyuria 5
- Delayed treatment: Begin rehydration immediately without waiting for laboratory confirmation of cholera 1
- Inadequate replacement: Cholera produces more severe fluid losses than other diarrheal illnesses, requiring more aggressive replacement 1, 4
- Inappropriate fluid choice: Avoid "clear liquids" commonly prescribed for other diarrheal illnesses; use properly formulated ORS instead 1
Special Considerations
- Provide additional plain drinking water at bedside to allow excretion of excess salt intake from ORS 1
- The glucose-sodium cotransport mechanism remains intact during cholera, making ORS highly effective 1
- Early antibiotic administration is particularly important for severely dehydrated patients to reduce their role as efficient disease transmitters 1