Treatment of Cholera
Aggressive oral rehydration therapy with WHO-ORS is the cornerstone of cholera treatment for mild to moderate dehydration, while severe dehydration requires immediate intravenous fluids (Ringer's lactate preferred), combined with doxycycline as first-line antibiotic therapy to reduce stool volume and duration by 50%. 1
Immediate Assessment and Fluid Replacement Strategy
The primary treatment goal is maintaining case fatality below 1% through rapid fluid replacement 1. Begin rehydration immediately without waiting for laboratory confirmation 1, 2.
Classify dehydration severity to guide treatment route: 3
- Mild dehydration (3-5% fluid deficit): ORS orally
- Moderate dehydration (6-9% fluid deficit): ORS orally with close monitoring
- Severe dehydration (≥10% fluid deficit): Immediate IV therapy
Oral Rehydration Therapy (ORT)
For mild to moderate dehydration, WHO-ORS is the primary treatment and most patients can be managed successfully with ORS alone in outpatient settings. 1 The treatment has two distinct phases 4:
- Rehydration phase (first 3-4 hours): Replace existing fluid deficits with ORS 5
- Maintenance phase: Match ongoing losses and provide adequate nutrition 4, 5
Critical implementation points:
- Cholera produces more severe fluid losses than other diarrheal illnesses, requiring more aggressive replacement 1, 3
- Provide additional plain drinking water at bedside to allow excretion of excess salt from ORS 1
- Monitor intake, output, and hydration status continuously 5
Intravenous Fluid Therapy
Indications for IV therapy: 1
- Severe dehydration with shock
- Altered mental status
- Inability to tolerate oral fluids
Ringer's lactate is the preferred IV solution, though normal saline may be used alongside ORS. 5 Exercise careful supervision to prevent fluid overload, particularly in children receiving IV rehydration 1, 3.
Antibiotic Therapy
Doxycycline is the preferred first-line antibiotic when available, reducing both stool volume and duration by approximately 50%. 1, 2 The FDA approves doxycycline specifically for cholera treatment 6.
Dosing Regimens
Adults: Single oral dose of 300 mg doxycycline 1
Children under 15 years: 6 mg/kg/day doxycycline (single dose) 1, 2
Alternative Antibiotics
Azithromycin has emerged as a highly effective alternative, particularly in areas with tetracycline resistance. 2 The WHO proposes azithromycin as first-choice and doxycycline as second-choice based on superior efficacy data 2.
Azithromycin dosing for children: 20 mg/kg (maximum 1 g, single dose) 2
Antibiotic Prioritization
Severely dehydrated patients are the highest priority for antibiotic therapy as they are the most efficient disease transmitters due to greater fecal losses. 1, 2 Administer antibiotics orally; parenteral administration offers no advantage 2.
Critical Pitfalls to Avoid
Do not use the following as first-line therapy: 2
- Ciprofloxacin: Systematic reviews demonstrate reduced effectiveness despite older recommendations
- Erythromycin: Inferior efficacy compared to azithromycin and causes more vomiting
- Trimethoprim-sulfamethoxazole: Less effective than doxycycline
Do not delay rehydration to obtain cultures or await confirmation. 2 The purging rate is highest initially but declines with time, especially when appropriate antibiotics are administered concurrently 3.
Monitoring Parameters
Continuously assess the following 1:
- Hydration status (dry mucous membranes indicate volume depletion) 3
- Pulse and perfusion (tachycardia reflects compensatory cardiovascular response) 3
- Mental status
- Signs of fluid overload, especially in pediatric patients 1
Geographic Considerations
In areas with known tetracycline resistance, consider azithromycin as first-line therapy 2. Local antibiotic sensitivity patterns should guide definitive therapy once culture results are available 2.