What is the recommended treatment for cholera, including fluid replacement (oral rehydration solution or intravenous Ringer's lactate), antibiotic selection and dosing (doxycycline, azithromycin, ceftriaxone, etc.), and zinc supplementation for adults, children older than 12 months, and pregnant women?

Cholera Treatment

For cholera, initiate aggressive fluid replacement with oral rehydration solution (ORS) for mild-to-moderate dehydration or intravenous Ringer's lactate for severe dehydration, followed by antimicrobial therapy with a single 300 mg dose of doxycycline (or azithromycin 1 g as a single dose for pregnant women and children), and continue fluid replacement matching ongoing stool losses until diarrhea resolves. 1, 2, 3

Fluid Replacement Strategy

Initial Rehydration Phase (First 3-4 Hours)

Assess dehydration severity clinically before selecting fluid route: 1, 4, 2

• Severe dehydration (≥10% deficit, shock, altered mental status, absent pulse): Administer Ringer's lactate or normal saline intravenously at 100 mL/kg over 3-4 hours (or 20 mL/kg boluses repeated until pulse, perfusion, and mental status normalize) 1, 4, 5

• Moderate dehydration (6-9% deficit, sunken eyes, decreased skin turgor): Use reduced-osmolarity ORS as first-line therapy; reserve IV fluids only if ORS fails or patient cannot tolerate oral intake 1

• Mild dehydration (3-5% deficit): Treat exclusively with ORS 1

Maintenance Phase (After Initial Rehydration)

Replace ongoing stool losses volume-for-volume with ORS until diarrhea stops: 1, 2

• Children <10 kg: 60-120 mL ORS after each diarrheal stool (up to ~500 mL/day) 1
• Children >10 kg: 120-240 mL ORS after each stool (up to ~1 L/day) 1
• Adolescents and adults: Ad libitum ORS (up to ~2 L/day), plus additional plain water as desired 1, 2

Critical point: Cholera patients can lose 10-20 liters of stool per day, so aggressive volume replacement matching purging rate is essential. 2

Antimicrobial Therapy

Administer antibiotics to all moderately and severely dehydrated cholera patients to reduce stool volume by 50% and shorten illness duration: 2, 3

First-Line Antibiotic Choices

• Adults and children >12 months: Doxycycline 300 mg single dose (equally effective as multi-dose tetracycline with better compliance) 3

• Pregnant women: Azithromycin 1 g single dose (doxycycline contraindicated in pregnancy) 1

• Children <12 months: Azithromycin 20 mg/kg single dose (maximum 1 g) 1

Alternative Antibiotics (if resistance documented)

• Ciprofloxacin 1 g single dose (adults) or 20 mg/kg single dose (children) 1
• Ceftriaxone 2 g IV daily for 3 days (for severe cases with suspected resistance) 1

Important caveat: Always obtain stool culture before antibiotics when possible, and adjust therapy based on local resistance patterns. 1

Zinc Supplementation

Administer zinc supplementation to children with cholera: 1

• Children 6 months to 5 years: Zinc 20 mg daily for 10-14 days 1
• Infants <6 months: Zinc 10 mg daily for 10-14 days 1
• Adults and pregnant women: No established benefit; not routinely recommended 1

Nutritional Management

Continue feeding throughout illness to prevent malnutrition: 1

• Breastfed infants: Continue breastfeeding without interruption 1
• Formula-fed infants: Continue full-strength formula (dilution not beneficial) 1
• Children and adults: Resume age-appropriate normal diet immediately after rehydration completes 1

Monitoring Parameters

Reassess hydration status every 3-4 hours during active treatment: 1, 6

• Pulse rate and quality
• Blood pressure and perfusion
• Mental status
• Urine output
• Weight changes
• Ongoing stool volume

Switch from IV to ORS once patient is alert, has normal perfusion, and can drink without vomiting. 1

Critical Pitfalls to Avoid

• Never use hypotonic saline (0.45% or 0.2% NaCl) for cholera rehydration - significantly increases hyponatremia risk 6

• Do not use commercial sports drinks, apple juice, or soft drinks as ORS substitutes - inappropriate osmolality and electrolyte composition 1

• Avoid antimotility agents (loperamide) in suspected cholera - may worsen outcomes and prolong bacterial shedding 1

• Do not delay fluid replacement while awaiting laboratory confirmation - clinical diagnosis and immediate treatment are lifesaving 2

• Ensure ORS preparation uses clean water - contaminated ORS can transmit cholera and worsen outcomes 7

• Do not underdose fluids - cholera's massive purging rate requires aggressive volume replacement matching losses 2, 5