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Defeating Cholera: Clinical Presentation and Management

U.S. Department of Health and Human Services, Public Health Services Centers for Disease Control, National Center for Infectious Diseases Division of Bacterial and Mycotic Diseases

Publication date: 06/01/1992


Table of Contents

Defeating Cholera: Clinical Presentation and Management

Symptoms of Moderate or Severe Cholera
Signs and Symptoms of Dehydration

Oral Rehydration
Guidelines for treating patients with some dehydration
Signs of adequate rehydration

Intravenous Rehydration
Guidelines for treating patients with severe dehydration

Antibiotics

References

For further information on cholera

POINT OF CONTACT FOR THIS DOCUMENT:


Defeating Cholera: Clinical Presentation and Management

Most persons infected with the cholera bacterium have mild diarrhea or no symptoms at all. Only about 7% of persons infected with the El Tor biotype of Vibrio cholerae O1 have illness requiring treatment at a health center. However, when cholera strikes in areas where practitioners are not acquainted with modern treatment methods, many people die.

Cholera patients should be evaluated and treated quickly. With proper treatment, even severely ill patients can be saved. Prompt restoration of lost fluids and salts is the primary goal of treatment.


Symptoms of Moderate or Severe Cholera

  • Profuse, watery diarrhea
  • Vomiting
  • Leg cramps

Signs and Symptoms of Dehydration

Some dehydration
  • Restlessness and irritability
  • Sunken eyes
  • Dry mouth and tongue
  • Increased thirst
  • Skin goes back slowly when pinched
Severe dehydration
  • Lethargy or unconsciousness
  • Very dry mouth and tongue
  • Skin goes back slowly when pinched
  • Weak or absent pulse
  • Low blood pressure

Oral Rehydration

Dehydrated patients who can sit up and drink should be given oral rehydration salts (ORS) solution immediately and be encouraged to drink. It is important to offer ORS solution frequently, measure the amount drunk, and measure the fluid lost as diarrhea and vomitus. Patients who vomit should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube.

Guidelines for treating patients with some dehydration

Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration.

--------------------------------------------------------------------------
Age *       <4 mo.   4-11 mo.   12-23 mo.   2-4 yr.    5-14 yr.  >or= 15yr.
Weight(kg)  <5       5-7.9      8-10.9      11-15.9    16-29.9   >or= 30
ml          200-400  400-600    600-800     800-1200   1200-2200 2200-4000
--------------------------------------------------------------------------

* Use the patient's age only when you do not know the weight. The approximate amount of ORS required (in milliliters) can also be calculated by multiplying the patient's weight in kg by 75.

If the patient requests more than the prescribed ORS solution, give more. Older children and adults should be offered plain water in addition to ORS solution.

For Infants:

  • Encourage the mother to continue breast-feeding.
  • Give infants under 6 months of age who are not breast-fed an additional 100-200 ml of clean water during this period.
Notes:

  1. The volumes and time shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
  2. During the initial stages of therapy, while still dehydrated, adults can consume as much as 1000 ml of ORS solution per hour, if necessary, andn children as much as 20 ml/kg body weight per hour.
  3. Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
  4. Resume feeding with a normal diet when vomiting has stopped.

Signs of adequate rehydration

  • Skin turgor is normal
  • Thirst has subsided
  • Urine has been passed
  • Pulse is strong

Intravenous Rehydration

Patients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Intravenous solutions

  • Best Ringer's Lactate Solution
  • Acceptable* Normal saline
Half normal saline with 5% glucose

  • Unacceptable Plain glucose (dextrose) solution
* These are acceptable in emergency, but do not correct acidosis and may worsen electrolyte imbalance.

Guidelines for treating patients with severe dehydration

Start intravenous fluids immediately. If the patient can drink, give ORS solution by mouth while the drip is set up. Give 100 ml/kg Ringer's Lactate Solution divided as follows:

Age                First give 30 ml/kg IV in:     Then give 70 ml/kg IV in:
---------------------------------------------------------------------------
Infants <12 mos.   1 hour*                        5 hours
Older   >1 yr.     30 minutes*                    2 1/2 hours
---------------------------------------------------------------------------

* Repeat once if radial pulse is still very weak or not detectable.

  • Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly.
  • Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink.
  • After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

Antibiotics

An antibiotic given orally will reduce the volume and duration of diarrhea. No other drugs for treatment of diarrhea or vomiting should be given.

Appropriate oral antibiotics (give one of these)

  • Doxycycline Adult: 300 mg in one dose
  • Tetracycline Adult: 500 mg, 4 times a day for 3 days Child: 12.5 mg/kg, 4 times a day for 3 days
  • Trimethoprim-sulfamethoxazole (TMP-SMX) Adult: 160 mg TMP and 800 mg SMX, 2 times a day for 3 days Child: 5 mg/kg TMP and 25 mg/kg SMX, 2 times a day for 3 days
  • Furazolidone Adult: 100 mg, 4 times a day for 3 days Child: 1.25 mg/kg, 4 times a day for 3 days
Doxycycline is the antibiotic of choice for adults (except pregnant women) because only one dose is required. TMP-SMX is the antibiotic of choice for children. Furazolidone is the antibiotic of choice for pregnant women. Erythromycin may be used when other antibiotics are not available, or the organism is resistant to them.


References

World Health Organization. A Manual for the Treatment of Diarrhoea. Geneva, Switzerland: World Health Organization, Programme for Control of Diarrhoeal Diseases, 1990. (WHO/CDD/SER/80.2 rev 2 (1990))

World Health Organization. Management of the Patient with Cholera. Geneva, Switzerland: World Health Organization, Programme for Control of Diarrhoeal Diseases, 1992. (WHO/CDD/SER/15 rev 1)


For further information on cholera

It is available from the Office of the Director, Mailstop C09, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control, 1600 Clifton Road, Atlanta, Georgia 30333. This brochure is in the public domain, and may be freely reproduced. It accompanies a video with the same title.


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DIVISION OF BACTERIAL & MYCOTIC DISEASES
CDC (NCID) Lynne McIntyre
1600 Clifton Rd NE, MS:(C-09)
Atlanta, GA 30333



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