Cholera Medication

Updated: Jun 22, 2017
  • Author: Sajeev Handa, MBBCh, BAO, LRCSI, LRCPI; Chief Editor: Russell W Steele, MD  more...
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Medication

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.

Travelers to cholera-affected regions should receive a cholera vaccine. The cholera vaccine Vaxchora is the only one approved by the FDA for cholera prevention. It is a live, weakened vaccine administered as a single, oral liquid dose of about three fluid ounces at least 10 days before travel to a cholera-affected region. The only other existing cholera-prevention vaccines require 2 doses, according to the Centers for Disease Control and Prevention (CDC). A single-dose vaccine is especially beneficial to a person who needs to travel to a cholera-affected region on short notice. [20]

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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.

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Vaccines

Class Summary

In June, 2016, the first U.S. cholera vaccine was approved by the FDA. [20]

Cholera vaccine (Vaxchora)

Contains live attenuated cholera bacteria that replicate in the gastrointestinal tract of the recipient to provide immunity. It is indicated for active immunization against disease caused by Vibrio cholerae serogroup O1 in adults aged 18-64 y traveling to cholera-affected areas.

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