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By ULY CLINIC

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Cholera


Cholera is an acute gastrointestinal infection caused by Vibrio cholerae. Infection occurs through ingestion of contaminated water or food by human faeces leading to severe diarrhoea and emesis associated with body fluid and electrolyte depletion.

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Diagnostic Criteria

 

  • A sudden onset of painless watery diarrhoea that may quickly become severe with profuse watery stools, vomiting, severe dehydration and muscular cramps, leading to hypovolemic shock and death

  • The stool has a characteristic “rice water” appearance (non-bilious, grey, slightly cloudy fluid with flecks of mucus, no blood and inoffensive odour)

 

Investigation

 

  • Laboratory evidence of dark field microscopic isolation of motile curved bacillus on a wet mount of fresh stool specimen. OR

  • Isolation of bacteria through stool culture on TCBS agar.

 

Note: When a case of cholera is suspected at home, advise to rehydrate the patient using ORS if available while preparing to take a patient to the nearest health facility or Cholera Treatment Centre

 

Note:

  • For confirmation at the beginning of an outbreak, rectal swab or stool specimen should be taken from first 5 to 10 suspected cases.

  • If any are positive, every tenth case will be sampled for specimen throughout the outbreak

  • Manage a suspected cholera case in an isolation ward or in an established Cholera Treatment Centre

 

Prevention

 

  • Drink water from safe sources (taps, decontaminated deep wells, bottles)

  • Boil water or treat it to kill bacteria and make it safe for drinking and other domestic uses

  • Wash hands with liquid soap and running water after visiting the toilet, before preparing foods, and before eating

  • DO NOT eat uncooked street food and do not eat cooked food that is no longer hot

  • DO NOT eat street prepared fresh fruits. Always eat home prepared fresh fruits

 

Management

 

Assess the patients level of dehydration as per National Guidelines for Prevention and Control of Cholera. It is of paramount importance to make correct diagnosis and administer the right treatment
according to the Treatment

  • Plan A: No dehydration

  • Plan B: Moderate dehydration and

  • Plan C: Severe dehydration.

 

Pharmacological Treatment:


For Severe dehydration:

 

  • Administer intravenous (IV) fluid immediately to replace fluid deficit; Use Ringer Lactate solution or, if that is not available, 0.9% sodium chloride solution.

  • 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 2.5 hours.

  • 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/hour) as soon as the patient can drink, in addition to IV fluid.

  •  If the patient can drink, begin giving A: 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. Give an oral antibiotic to patients with severe dehydration as follows:

 

Adults (Not for pregnant women)
 

  • Doxycycline (PO) 300 mg as a single dose or 5mg/kg single dose OR

  • Ciprofloxacin (PO) 1g stat or 15mg/kg 12 hourly for 3 day
    AND 

  • Folic acid (PO) 5mg once daily for the duration of the treatment.

 

Expectant mothers:

 

  • A: Erythromycin (PO) 500mg 8 hourly for 5 days

 

Children:

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  • Erythromycin syrup (PO) 12.5mg/kg 6 hourly for 3 days OR

  • Co-trimoxazole 48mg/kg once a day for 3 days

 

For adolescents:

 

  • Ciprofloxacin (PO) 12mg/kg 2 times for 3 days

OR

  • Doxycycline (PO) 300mg as single dose or 5mg/kg single dose

AND

  • Folic acid (PO) 2.5mg once daily for children < 6 months, or 5mg once daily for children >6 months for the duration of the treatment

AND

  • Zinc (PO) 10mg once daily for children <6months, or 20mg once daily for children >6 months for duration of 10 days

 

Note:

  • Ciprofloxacin was previously contraindicated to children under 12 years. Recent studies have shown it to be safe for use in children

  • Start feeding 3-4 hours after oral rehydration begins. Preferably, give antibiotics with food to minimize vomiting

 

For moderate Dehydration

 

  • Give oral rehydration, approximately 75-100ml/kg in the first four hours

  • Reassess after four hours; if improved, continue giving WHO based ORS, in quantity corresponding to losses (eg. after each stool) or 10 to 20ml/kg. If not improved, treat as severe

 

If 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

  • Instruct the patient or the caretaker to return if any of the following signs develop; increased number of watery stools repeated vomiting or any signs indicating other problems (eg, fever, blood in stool)

 

Note:

 

Prophylaxis of cholera contacts is not recommended. Routine treatment of a community with antibiotics, or mass chemoprophylaxis, has no effect on the spread of cholera, can have adverse effects by increasing antimicrobial resistance and provides a false sense of security.

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Updated on, 28.10.2020

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References

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1. STG page number 10-12

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