Medication Summary
Antimicrobial therapy for cholera is an adjunct to fluid therapy and is not an essential therapeutic component. However, an effective antibiotic can reduce the volume of diarrhea in patients with severe cholera and shorten the period during which Vibrio cholerae O1 is excreted. In addition, it usually stops the diarrhea within 48 hours, thus shortening the period of hospitalization. No other drugs besides antibiotics should be used in the treatment of cholera.
The choice of antibiotics is determined by the susceptibility patterns of the local strains of V cholerae O1 or O139.
If antimicrobial therapy is to be initiated, it should be given when the patient is first seen and cholera is suspected. Little reason exists to wait for culture and susceptibility reports.
Furazolidone has been the agent routinely used in the treatment of cholera in children; however, resistance has been reported, and ampicillin, erythromycin, and fluoroquinolones are potentially effective alternatives. The use of quinolones is contraindicated in children with cholera.
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Although not necessarily curative, treatment with an antibiotic to which the organism is susceptible diminishes the duration and volume of the fluid loss and hastens clearance of the organism from stool. Pharmacotherapy plays a secondary role in the management of cholera; fluid replacement is primary.
Emerging drug resistance in certain parts of the world is a concern, as some V cholerae strains contain plasmids that confer resistance to many antibiotics. In areas of known tetracycline resistance, therapeutic options include ciprofloxacin and erythromycin. Strains resistant to ciprofloxacin have been reported from Calcutta, India.
Chemoprophylaxis of household contacts is not necessary.
Doxycycline (Adoxa, Vibramycin, Doxy)
Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Tetracycline
Tetracycline inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). This agent treats gram-positive and gram-negative organisms and mycoplasmal, chlamydial, and rickettsial infections.
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra DS)
This combination agent inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Trimethoprim is a dihydrofolate reductase inhibitor that prevents tetrahydrofolic acid production in bacteria. It is active in vitro against a broad range of gram-positive and gram-negative bacteria, including uropathogens (eg, Enterobacteriaceae and Staphylococcus saprophyticus). Resistance is usually mediated by decreased cell permeability or alterations in amount or structure of dihydrofolate reductase. It demonstrates synergy with sulfonamides, potentiating inhibition of bacterial tetrahydrofolate production.
Ciprofloxacin (Cipro, Proquin XR)
Ciprofloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, methicillin-resistant Staphylococcus aureus (MRSA), S epidermidis, and most gram-negative organisms. It does not have activity against anaerobes. This agent inhibits bacterial DNA synthesis and, consequently, growth.
Ampicillin
Ampicillin has bactericidal activity against susceptible organisms.
Erythromycin (E.E.S., Erythrocin, Ery-Tab)
Erythromycin inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer RNA (tRNA) from ribosomes, causing RNA-dependent protein synthesis to arrest. Erythromycin is used for treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dose. When twice-daily dosing is desired, half the total daily dose may be taken q12h. For more severe infections, double the dose.
Azithromycin (Zithromax, Zmax)
This agent acts by binding to the 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
It concentrates in phagocytes and fibroblasts, as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. This agent is used to treat mild-to-moderate microbial infections.
Norfloxacin (Noroxin)
Norfloxacin is a fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms. It does not have activity against anaerobes. It inhibits bacterial DNA synthesis and growth.
Centers for Disease Control and Prevention. Cholera. Available at http://www.cdc.gov/cholera/index.html. Accessed July 7, 2011.
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Kenneth Todar. Todar's Online Textbook of Bacteriology. Available at http://textbookofbacteriology.net/cholera.html. Accessed April 12, 2010.
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- Table 1. Assessment of the Patient With Diarrhea for Dehydration (based on WHO classification)
- Table 2. Fluid Replacement for Dehydration
- Table 3. Approximate Amount of Oral Rehydration Solution to Administer in the First 4 Hours
- Table 4. Estimate of Oral Rehydration Solution Packets to Be Administered at Home
- Table 5. Oral Replacement Solution for Maintenance of Hydration
- Table 6. Antimicrobial Therapy Used in the Treatment of Cholera*
- Table 7. WHO Guidelines for Cholera Management
| Sensorium | Eyes | Thirst | Skin Pinch | Decision |
| Abnormally sleepy or lethargic | Sunken | Drinks poorly or not at all | Goes back very slowly (>2 sec) | If the patient has 2 or more of these signs, severe dehydration is present |
| Restless, irritable | Sunken | Drinks eagerly | Goes back slowly (< 2 sec) | If the patient has 2 or more signs, some dehydration is present |
| Well, alert | Normal | Drinks normally, not thirsty | Goes back quickly | Patient has no dehydration |
| Severe dehydration | Intravenous (IV) drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined below |
|
| Some dehydration | Oral rehydration salts (amount in first 4 h) |
|
| No dehydration | Oral rehydration salts |
|
| Age | < 4 mo | 4-11 mo | 12-23 mo | 2-4 y | 5-14 y | ≥15 y |
| Weight | < 5 kg | 5-7.9 kg | 8-10.9 kg | 11-15.9 kg | 16-29.9 kg | ≥30 kg |
| ORS solution in mL | 200-400 | 400-600 | 600-800 | 800-1200 | 1200-2200 | 2200-4000 |
| Age | Amount of Solution After Each Loose Stool | ORS Packets Needed |
| < 24 mo | 50-100 mL | Enough for 500 mL/d |
| 2-9 y | 100-200 mL | Enough for 1000 mL/d |
| ≥10 y | As much as is wanted | Enough for 200 mL/d |
| Age | Amount of Solution After Each Loose Stool |
| < 24 mo | 100 mL |
| 2-9 y | 200 mL |
| ≥10 y | As much as is wanted |
| Antibiotic | Single Dose (PO) | Multiple Dose (PO) |
| Doxycycline† | 7 mg/kg; not to exceed 300 mg/dose‡ | 2 mg/kg bid on day 1; then 2 mg/kg qd on days 2 and 3; not to exceed 100 mg/dose |
| Tetracycline† | 25 mg/kg; not to exceed 1 g/dose‡ | 40 mg/kg/d divided qid for 3 d; not to exceed 2 g/d |
| Furazolidone | 7 mg/kg; not to exceed 300 mg/dose | 5 mg/kg/d divided qid for 3 d; not to exceed 400 mg/d |
| Trimethoprim and sulfamethoxazole | Not evaluated | < 2 months: Contraindicated ≥2 months: 5-10 mg/kg/d (based on trimethoprim component) divided bid for 3 d; not to exceed 320 mg/d trimethoprim and 1.6 g/d of sulfamethoxazole |
| Ciprofloxacin§ | 30 mg/kg; not to exceed 1 g/dose‡ | 30 mg/kg/d divided q12h for 3 d; not to exceed 2 g/d |
| Ampicillin | Not evaluated | 50 mg/kg/d divided qid for 3 d; not to exceed 2 g/d |
| Erythromycin | Not evaluated | 40 mg/kg/d erythromycin base divided tid for 3 d; not to exceed 1 g/d |
| * Antimicrobial therapy is an adjunct to fluid therapy of cholera and is not an essential component. However, it reduces diarrhea volume and duration by approximately 50%. The choice of antibiotics is determined by the susceptibility patterns of the local strains of V cholerae O1 or O139. † Tetracycline and doxycycline can discolor permanent teeth of children younger than 8 years. However, the risk is small when these drugs are used for short courses of therapy, especially if used in a single dose. ‡ Single-dose therapy of these drugs has not been evaluated systematically in children, and recommendations are extrapolated from experience in adults. § Fluoroquinolones (eg, ciprofloxacin) are not approved in the United States for use in persons younger than 18 years. When given in high doses to juvenile animals, they cause arthropathy. Clinical experience indicates that this risk is very small in children when used for short courses of therapy. | ||
| Steps in the treatment of a patient with suspected cholera are as follows: |
| 1. Assess for dehydration (see Table 1) |
| 2. Rehydrate the patient and monitor frequently, then reassess hydration status |
| 3. Maintain hydration; replace ongoing fluid losses until diarrhea stops |
| 4. Administer an oral antibiotic to the patient with severe dehydration |
| 5. Feed the patient |
| More detailed guidelines for the treatment of cholera are as follows: |
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