Cholera Treatment & Management

Author: Vidhu V Thaker, MBBCh, MD; Chief Editor: Russell W Steele, MD more...

Updated: Jul 19, 2011

What would you like to print?

Approach Considerations
Treatment Guidelines
Cholera Cots
Rehydration
Maintenance of Hydration
Antibiotic Treatment
Fluid Replacement for Dehydration
Oral Rehydration During First 4 Hours
Oral Rehydration for Home Administration
Oral Replacement Solution for Hydration Maintenance
Antimicrobial Therapy for Cholera
WHO Guidelines for Cholera Management
Diet
Show All

Approach Considerations

Rehydration is the first priority in the treatment of cholera. Rehydration is accomplished in 2 phases: rehydration and maintenance.

The goal of the rehydration phase is to restore normal hydration status, which should take no more than 4 hours. Set the rate of intravenous infusion in severely dehydrated patients at 50-100 mL/kg/hr. Lactated Ringer solution is preferred over isotonic sodium chloride solution because saline does not correct metabolic acidosis

The goal of the maintenance phase is to maintain normal hydration status by replacing ongoing losses. The oral route is preferred, and the use of oral rehydration solution (ORS) at a rate of 500-1000 mL/hr is recommended.

Treatment Guidelines

The World Health Organization (WHO) guidelines for the management of cholera are practical, easily understood, and readily applied in clinical practice (see Table 7). These guidelines can be used for the treatment of any patient with diarrhea and dehydration. Diagnosis of cholera is not required to initiate hydration therapy.

Cholera Cots

In areas where cholera is endemic, cholera cots have been used to assess the volume of ongoing stool losses. A cholera cot is a cot covered by a plastic sheet with a hole in the center to allow the stool to collect in a calibrated bucket underneath.

Use of such a cot allows minimally trained health workers to calculate fluid losses and replacement needs. The volume of stool is measured every 2-4 hours, and the volume of fluid administered is adjusted accordingly.

In the initial phase of therapy, urine losses account for only a small proportion of fluid losses, and the amount of fluid in the bucket is an adequate reflection of stool losses. With rehydration, urine should be collected separately, so that a vicious circle of increasing urine output and overhydration can be avoided.

Rehydration

The WHO has provided recommendations for fluid replacement in patients with dehydration^[13](see Table 2). The recommendations include recommendations for fluid replacement for severe hydration, some dehydration, and no dehydration.

Severe dehydration

Administer intravenous (IV) fluid immediately to replace fluid deficit. Use lactated Ringer solution or, if that is not available, isotonic sodium chloride solution. If the patient can drink, begin giving oral rehydration salt solution (ORS) by mouth while the drip is being set up; ORS can provide the potassium, bicarbonate, and glucose that saline solution lacks.

For patients older than 1 year, give 100 mL/kg IV in 3 hours—30 mL/kg as rapidly as possible (within 30 min) then 70 mL/kg in the next 2 hours. For patients younger than 1 year, administer 100 mL/kg IV in 6 hours—30 mL/kg in the first hour then 70 mL/kg in the next 5 hours.

Monitor the patient frequently. After the initial 30 mL/kg has been administered, the radial pulse should be strong and blood pressure should be normal. If the pulse is not yet strong, continue to give IV fluid rapidly. Administer ORS solution (about 5 mL/kg/h) as soon as the patient can drink, in addition to IV fluid.

Reassess the hydration status after 3 hours (infants after 6 h), using Table 1. In the rare case that the patient still exhibits signs of severe dehydration, repeat the IV therapy already given. If signs of some dehydration are present, continue as indicated below for some dehydration. If no signs of dehydration exist, maintain hydration by replacing ongoing fluid losses.

Routes for parenteral rehydration

Accessing a peripheral vein is relatively easy, despite the severe dehydration. If a peripheral vein is not readily accessible, scalp veins have been used for initial rehydration. As the vascular volume is reestablished, a larger needle or catheter can be introduced in a peripheral vein.

Intraosseous routes have been used successfully in young children when veins cannot be accessed. The intraperitoneal route has been tried, but is not recommended.

ORS solution can be administered via nasogastric tube if the patient has some signs of dehydration and cannot drink or if the patient has severe dehydration and IV therapy is not possible at the treatment facility.

Overhydration

A risk of overhydration exists with intravenous fluids; it usually first manifests as puffiness around the eyes. Continued excessive administration of intravenous fluids can lead to pulmonary edema and has been observed even in children with normal cardiovascular reserve. Thus, it is important to monitor patients who are receiving intravenous rehydration hourly. Serum-specific gravity is an additional measure of the adequacy of rehydration.

Some dehydration

Administer ORS solution according to the amount recommended in Table 3. WHO ORS contains the following:

Sodium – 75 mmol/L
Chloride – 65 mmol/L
Potassium – 20 mmol/L
Bicarbonate – 30 mmol/L
Glucose – 111 mmol/L

A homemade equivalent is 6 teaspoons of sugar and one half teaspoon of salt in a liter of water; a half cup of orange juice or some mashed banana can provide potassium.^[14]

Use the patient's age only when weight is unknown. The approximate amount of ORS required (in mL) also can be calculated by multiplying the patient's weight (in kg) times 75.

If the patient passes watery stools or wants more ORS solution than shown, give more. Monitor the patient frequently to ensure that the ORS solution is taken satisfactorily and to identify patients with profuse ongoing diarrhea who require closer monitoring.

Reassess the patient after 4 hours, using Table 1. In the rare case where signs of severe dehydration have appeared, rehydrate for severe dehydration, as above. If some dehydration is still present, repeat the procedures for some dehydration and start to offer food and other fluids. If no signs of dehydration are present, maintain hydration by replacing ongoing fluid losses.

Most patients absorb enough ORS solution to achieve rehydration, even when they are vomiting. Vomiting usually subsides within 2-3 hours, as rehydration is achieved.

Urine output decreases as dehydration develops and may cease. It usually resumes within 6-8 hours after starting rehydration. Regular urinary output (ie, every 3-4 h) is a good sign that enough fluid is being given.

No signs of dehydration

Patients who have no signs of dehydration when first observed can be treated at home. Give these patients ORS packets to take home, enough for 2 days. Demonstrate how to prepare and give the solution. The caretaker should give the patient the amount of ORS solution shown in Table 4.

Instruct the patient or the caretaker to return if any of the following signs develop:

Increased number of watery stools
Eating or drinking poorly
Marked thirst
Repeated vomiting
Any signs indicating other problems (eg, fever, blood in stool)

Maintenance of Hydration

Maintain hydration of patients presenting with severe or some dehydration. Replace ongoing fluid losses until diarrhea stops.

When a patient who has been rehydrated with IV fluid or ORS solution is reassessed and has no signs of dehydration, continue to administer ORS solution to maintain normal hydration. The aim is to replace stool losses as they occur with an equivalent amount of ORS solution. See Table 5 .

The amount of ORS solution required to maintain hydration varies greatly among patients, depending on the volume of stool passed. It is highest in the first 24 hours of treatment and is especially large in patients who present with severe dehydration. In the first 24 hours, the average requirement of ORS solution in such patients is 200 mL/kg, but some patients may need as much as 350 mL/kg.

Continue to reassess the patient for signs of dehydration at least every 4 hours to ensure that enough ORS solution is being taken. Patients with profuse ongoing diarrhea require more frequent monitoring. If signs of some dehydration are detected, the patient should be rehydrated as described earlier, before continuing with treatment to maintain hydration.

A few patients, whose ongoing stool output is very large, may have difficulty in drinking the volume of ORS needed to maintain hydration. If these patients become tired, vomit frequently, or develop abdominal distension, ORS solution should be stopped and hydration should be maintained intravenously with lactated Ringer solution or isotonic sodium chloride solution, administering 50 mL/kg in 3 hours. After this is done, resuming treatment with ORS solution is usually possible.

Keep the patient under observation, if possible, until diarrhea stops or is infrequent and of small volume. This is especially important for any patient presenting with severe dehydration. If a patient must be discharged from the hospital before diarrhea has stopped, show the caretaker how to prepare and give ORS solution, and instruct the caretaker to continue to give ORS solution, as above. Also instruct the caretaker to return the patient to the hospital if any signs of danger appear.

Antibiotic Treatment

An effective antibiotic can reduce the volume of diarrhea in patients with severe cholera and shorten the period during which V cholerae O1 is excreted. In addition, it usually stops the diarrhea within 48 hours, thus shortening the period of hospitalization. Whenever possible, antibiotic therapy should be guided by susceptibility reports.

Antibiotic treatment is indicated for severely dehydrated patients who are older than 2 years. Begin antibiotic therapy after the patient has been rehydrated (usually in 4-6 h) and vomiting has stopped. No advantage exists to using injectable antibiotics, which are expensive. No other drugs should be used in the treatment of cholera. Antimicrobial agents typically are administered for 3-5 days (see Table 6). However, single-dose therapy with tetracycline, doxycycline, furazolidone, or ciprofloxacin has been shown effective in reducing the duration and volume of diarrhea.

Fluid Replacement for Dehydration

Table 2. Fluid Replacement for Dehydration (Open Table in a new window)

Severe dehydration	Intravenous (IV) drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined below	100 mL/kg in 3-h period (in 6 h for children < 1 y) Start rapidly (30 mL/kg within 30 min, then slow down) Total amount for first 24 h: 200 L/kg
Some dehydration	Oral rehydration salts (amount in first 4 h)	Infants < 4 mo (< 5 kg): 200–400 mL Infants 4–11 mo (5–7.9 kg): 400–600 mL Children 1–2 y (8–10.9 kg): 600–800 mL Children 2–4 y (11–15.9 kg): 800–1200 mL Children 5–14 y (16–29.9 kg): 1200–2200 mL Patients >14 y (≥30 kg): 2200–4000 mL
No dehydration	Oral rehydration salts	Children < 2 y: 50–100 mL, up to 500 mL/day Children 2–9 y: 100–200 mL, up to 1000 mL/day Patients >9 y: As much as wanted, up to 2000 mL/day

Oral Rehydration During First 4 Hours

Table 3. Approximate Amount of Oral Rehydration Solution to Administer in the First 4 Hours (Open Table in a new window)

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

Oral Rehydration for Home Administration

Table 4. Estimate of Oral Rehydration Solution Packets to Be Administered at Home (Open Table in a new window)

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

Oral Replacement Solution for Hydration Maintenance

Table 5. Oral Replacement Solution for Maintenance of Hydration (Open Table in a new window)

Age	Amount of Solution After Each Loose Stool
< 24 mo	100 mL
2-9 y	200 mL
≥10 y	As much as is wanted

Antimicrobial Therapy for Cholera

Table 6. Antimicrobial Therapy Used in the Treatment of Cholera* (Open Table in a new window)

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.

WHO Guidelines for Cholera Management

Table 7. WHO Guidelines for Cholera Management (Open Table in a new window)

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:
Evaluate the degree of dehydration upon arrival
Rehydrate the patient in 2 phases; these include rehydration (for 2-4 h) and maintenance (until diarrhea abates)
Register output and intake volumes on predesigned charts and periodically review these data
Use the intravenous route only (1) during the rehydration phase for severely dehydrated patients for whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers (ie, >10 mL/kg/h)
During the maintenance phase, use oral rehydration solution at a rate of 800-1000 mL/h; match ongoing losses with ORS administration
Discharge patients to the treatment center if oral tolerance is greater than or equal to 1000 mL/h, urine volume is greater than or equal to 40 mL/h, and stool volume is less than or equal to 400 mL/h.

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:

Evaluate the degree of dehydration upon arrival

Rehydrate the patient in 2 phases; these include rehydration (for 2-4 h) and maintenance (until diarrhea abates)

Use the intravenous route only (1) during the rehydration phase for severely dehydrated patients for whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers (ie, >10 mL/kg/h)

During the maintenance phase, use oral rehydration solution at a rate of 800-1000 mL/h; match ongoing losses with ORS administration

Discharge patients to the treatment center if oral tolerance is greater than or equal to 1000 mL/h, urine volume is greater than or equal to 40 mL/h, and stool volume is less than or equal to 400 mL/h.

Diet

Resume feeding with a normal diet when vomiting has stopped. Continue breastfeeding infants and young children.

Malnutrition after infection is not a major problem, as it is after infection with Shigella species or rotavirus diarrhea. The catabolic cost of the infection is relatively low, anorexia is neither profound nor persistent, and intestinal enzyme activity remains intact after infection; hence, intestinal absorption of nutrients is near normal.

There is no reason to withhold food from cholera patients.

Proceed to Medication

Contributor Information and Disclosures

Author

Vidhu V Thaker, MBBCh, MD Attending Pediatrician, Haverstraw Pediatrics; Clinical Assistant Professor of Pediatrics, New York Medical College

Vidhu V Thaker, MBBCh, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Association of Subspecialty Professors, Infectious Diseases Society of America, and Sigma Xi

Disclosure: emedicine $50.00 Author of chapter; MERCK None Other

Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI, Director, Division of Hospital Medicine, Department of Medicine, Rhode Island Hospital

Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI, is a member of the following medical societies: Infectious Diseases Society of America and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

Centers for Disease Control and Prevention. Cholera. Available at http://www.cdc.gov/cholera/index.html. Accessed July 7, 2011.
CDC. 150th anniversary of John Snow and the pump handle. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5334a1.htm. Accessed March 29, 2006.
Kenneth Todar. Todar's Online Textbook of Bacteriology. Available at http://textbookofbacteriology.net/cholera.html. Accessed April 12, 2010.
Sack D, Cadoz M. Cholera vaccines. In: Plotkin SA, Orenstein WA. Vaccines. Philadelphia: WB Saunders Company; 1999:639-649.
Steinberg EB, Greene KD, Bopp CA, Cameron DN, Wells JG, Mintz ED. Cholera in the United States, 1995-2000: trends at the end of the twentieth century. J Infect Dis. Sep 15 2001;184(6):799-802. [Medline].
Tobin-D'Angelo M, Smith AR, Bulens SN, et al. Severe diarrhea caused by cholera toxin-producing vibrio cholerae serogroup O75 infections acquired in the southeastern United States. Clin Infect Dis. Oct 15 2008;47(8):1035-40. [Medline].
CDC. Two cases of toxigenic Vibrio cholerae O1 infection after Hurricanes Katrina and Rita--Louisiana, October 2005. MMWR Morb Mortal Wkly Rep. Jan 20 2006;55(2):31-2. [Medline].
WHO. Cholera vaccines: WHO position paper. World Health Organization. Available at http://www.who.int/wer/2010/wer8513.pdf. Accessed April 13th, 2010.
WHO. Cholera Country Profiles. World Health Organization. Available at http://www.who.int/cholera/countries/en/index.html. Accessed April 12th, 2009.
Pan American Health Organization. EOC Situation Report - Cholera Outbreak #20. Pan American Health Organization. Available at http://new.paho.org/blogs/haiti/?p=2034. Accessed July 17th, 2011.
CDC journal study ‘strongly suggests' U.N. peacekeepers from Nepal imported cholera to Haiti. Washington Post.. June 29, 2011;[Full Text].
Chin CS, Sorenson J, Harris JB, Robins WP, Charles RC, Jean-Charles RR, et al. The origin of the Haitian cholera outbreak strain. N Engl J Med. Jan 6 2011;364(1):33-42. [Medline]. [Full Text].
CDC. 2010 Haiti Cholera Outbreak. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/haiticholera/diagnosistreatment.htm. Accessed 10/29/2010.
Rehydration Project. Oral Rehydration Solutions: Made at Home. Available at http://rehydrate.org/solutions/homemade-ors.pdf. Accessed July 7, 2011.
WHO. Cholera vaccines: WHO position paper. Wkly Epidemiol Rec. Mar 26 2010;85(13):117-28. [Medline].
Sinclair D, Abba K, Zaman K, Qadri F, Graves PM. Oral vaccines for preventing cholera. Cochrane Database Syst Rev. Mar 16 2011;CD008603. [Medline].

Electron microscopic image of Vibrio cholerae

Scanning electron microscope image of Vibrio cholerae bacteria, which infect the digestive system.

This scanning electron micrograph (SEM) depicts a number of Vibrio cholerae bacteria of the serogroup 01; magnified 22371x. Image courtesy of CDC/Janice Haney Carr.

This patient with cholera is drinking oral rehydration solution (ORS) in order to counteract the cholera-induced dehydration. Image courtesy of the CDC.

Table 1. Assessment of the Patient With Diarrhea for Dehydration (based on WHO classification)

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

Table 2. Fluid Replacement for Dehydration

Severe dehydration	Intravenous (IV) drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined below	100 mL/kg in 3-h period (in 6 h for children < 1 y) Start rapidly (30 mL/kg within 30 min, then slow down) Total amount for first 24 h: 200 L/kg
Some dehydration	Oral rehydration salts (amount in first 4 h)	Infants < 4 mo (< 5 kg): 200–400 mL Infants 4–11 mo (5–7.9 kg): 400–600 mL Children 1–2 y (8–10.9 kg): 600–800 mL Children 2–4 y (11–15.9 kg): 800–1200 mL Children 5–14 y (16–29.9 kg): 1200–2200 mL Patients >14 y (≥30 kg): 2200–4000 mL
No dehydration	Oral rehydration salts	Children < 2 y: 50–100 mL, up to 500 mL/day Children 2–9 y: 100–200 mL, up to 1000 mL/day Patients >9 y: As much as wanted, up to 2000 mL/day

Table 3. Approximate Amount of Oral Rehydration Solution to Administer in the First 4 Hours

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

Table 4. Estimate of Oral Rehydration Solution Packets to Be Administered at Home

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

Table 5. Oral Replacement Solution for Maintenance of Hydration

Age	Amount of Solution After Each Loose Stool
< 24 mo	100 mL
2-9 y	200 mL
≥10 y	As much as is wanted

Table 6. Antimicrobial Therapy Used in the Treatment of Cholera*

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.

Table 7. WHO Guidelines for Cholera Management

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:
Evaluate the degree of dehydration upon arrival
Rehydrate the patient in 2 phases; these include rehydration (for 2-4 h) and maintenance (until diarrhea abates)
Register output and intake volumes on predesigned charts and periodically review these data
Use the intravenous route only (1) during the rehydration phase for severely dehydrated patients for whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers (ie, >10 mL/kg/h)
During the maintenance phase, use oral rehydration solution at a rate of 800-1000 mL/h; match ongoing losses with ORS administration
Discharge patients to the treatment center if oral tolerance is greater than or equal to 1000 mL/h, urine volume is greater than or equal to 40 mL/h, and stool volume is less than or equal to 400 mL/h.