Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild-moderate volume depletion: without vomiting

1st line – oral rehydration

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ACUTE
|
mild-moderate volume depletion: without vomiting
1st line – 

oral rehydration

If patients are able to take significant amounts of oral fluid when offered, oral rehydration is usually preferred. This has the added benefit of avoiding the complications of intravenous fluids, such as infection at the catheter site, pain, and needlestick injuries.

Duration of therapy: aggressive catch-up rehydration for 2 to 4 hours is followed by maintenance fluids until diarrhea abatement, which is usually 2 to 5 days later. Accurate fluid balance is needed; hence the use of the cholera cot, which enables the patient to purge while lying flat and the medical staff to measure the enteric loss. The aim is to replace hourly losses with an equal volume of oral or intravenous fluids. Accounting for insensible losses is also important. For example, a 60-kg patient needs approximately 480 to 960 mL every 24 hours or 20 to 40 mL per hour to make up for insensible losses. For a 6-kg child, using an assumption of 0.3 to 0.5 mL/kg/hour, the maintenance is 2 mL per hour to make up for insensible losses. Precisely calculating volume depletion is difficult. The equations provided may be used in balance with clinical judgment.

Several types of oral replacement solution (ORS) are available: in the epidemic setting, the standard World Health Organization ORS come prepacked and contain (all in mOsm/L): Na+ 75, K+ 20, Cl- 65, citrate 10, and glucose 75, with an osmolality of 245 mOsm/L. However, if possible, rice-based ORS with a similar concentration of electrolytes should be used for cholera because this reduces the volume of purging. The use of polymer‐based ORS (e.g., rice- or wheat-based products) may be associated with reduced stool volume and duration of diarrhea compared with glucose-based ORS.[95]

Care should be taken in the epidemic setting to ensure that the water used for ORS has been boiled or appropriately treated.

Plus – supportive care

Back
ACUTE
|
mild-moderate volume depletion: without vomiting
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with moderate volume depletion and those with high rates of purging (e.g., >1 L per hour) should be nursed on a cholera cot. Isolation of cases is usually difficult in outbreaks but essential in developed-world settings when returning travelers are being managed. The organism is not difficult to kill with standard cleaning agents available in medical facilities.

Plus – age-appropriate diet resumption

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ACUTE
|
mild-moderate volume depletion: without vomiting
Plus – 

age-appropriate diet resumption

Treatment recommended for ALL patients in selected patient group

Patients should be given a normal diet as soon as they are able to eat, including reinstituting breast-feeding as soon as possible after the initial catch-up rehydration phase has been completed.

Plus – antibiotic therapy

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ACUTE
|
mild-moderate volume depletion: without vomiting
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotics can reduce diarrhea volume and duration and shorten the period of Vibrio cholerae shedding.[96]

Current guidelines recommend single-dose oral antibiotic treatment for patients who: are severely ill; have severe, or some level of, dehydration with high school purging; are pregnant; or have comorbidities (e.g., HIV) that pose elevated risk in cholera illness.[44][96][97][98][99]​ Antibiotic therapy should be given as soon as the patient can tolerate oral medication.

Single-dose doxycycline is recommended as first-line treatment for adults (including pregnant women) and children. Historically, tetracyclines were contraindicated for pregnant women due to concerns about potential teratogenic effects, and for children younger than age 8 years due to risk of dental discoloration. However, a recent systematic review did not demonstrate such correlations with the use of doxycycline.[100]

While doxycycline is the preferred first-line treatment, the choice of antibiotic should be informed by local antibiotic susceptibility patterns. If resistance to doxycycline is documented, a single dose of azithromycin or ciprofloxacin is recommended as an alternative option.[98][99]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[101]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

In low-income countries, antibiotic choice is likely to be limited by what is available in sufficient quantities to cope with high demand, and susceptibility testing is likely to take longer than the mean duration of illness, forcing empiric therapy. A wide range of antibiotics have shown activity against V cholerae, including tetracyclines (e.g., doxycycline, tetracycline), fluoroquinolones (e.g., ciprofloxacin), sulfa drugs (e.g., trimethoprim/sulfamethoxazole), and macrolides (e.g., erythromycin, azithromycin). Consult a specialist for guidance on choice of antibiotic if first-line or alternative treatments are unsuitable.

Primary options

doxycycline: children <12 years of age: 2-4 mg/kg orally as a single dose; children ≥12 years of age and adults: 300 mg orally as a single dose

Secondary options

azithromycin: children <12 years of age: 20 mg/kg orally as a single dose, maximum 1000 mg/dose; children ≥12 years of age and adults: 1000 mg orally as a single dose

OR

ciprofloxacin: children <12 years of age: 20 mg/kg orally as a single dose, maximum 1000 mg/dose; children ≥12 years of age and adults: 1000 mg orally as a single dose

Consider – zinc supplementation in children

Back
ACUTE
|
mild-moderate volume depletion: without vomiting
Consider – 

zinc supplementation in children

Treatment recommended for SOME patients in selected patient group

There is little good evidence for vitamin and micronutrient supplements in treatment of cholera, with the exception of zinc in children.

A trial that looked at the effect of oral zinc supplementation in children with cholera found that zinc supplementation significantly reduced the duration and severity of diarrhea.[104]

The mechanism is likely due to an effect on enterocyte ion transportation, with zinc opposing the cholera-toxin-induced electrolyte secretion.[105]

Taken until recovery.

Primary options

zinc sulfate: children: 30 mg orally once daily

More

Consider – vitamin A supplementation in children

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ACUTE
|
mild-moderate volume depletion: without vomiting
Consider – 

vitamin A supplementation in children

Treatment recommended for SOME patients in selected patient group

The World Health Organization recommends vitamin A supplementation for children above 6 months of age in resource-poor settings where malnutrition is likely to be a problem. Children with diarrhea in these settings are particularly at risk of vitamin A deficiency and should receive high-dose supplementation.[106][107][108]​ A Cochrane review has shown that in children ages 6 months to 5 years living in rural or urban/periurban settings, vitamin A supplementation is associated with a clinically meaningful reduced risk of all-cause mortality; specifically, with a 12% reduction in overall mortality and death due to diarrhea.[109]

Primary options

vitamin A (retinol): children 6-11 months of age: 100,000 international units orally as a single dose; children 12-59 months of age: 200,000 international units orally every 4-6 months

vomiting or severe volume depletion

1st line – intravenous rehydration

Back
ACUTE
|
vomiting or severe volume depletion
1st line – 

intravenous rehydration

Catch-up fluid is given over the first 2 to 4 hours, followed by replacement fluid for ongoing losses. Calculating required fluid may be done using the simple equation: % dehydration x body weight (kg) = number of liters fluid required. For example, a 60-kg patient who presents with severe (10%) volume depletion will need 6 liters of intravenous fluid over 2 to 4 hours or 1.5 to 3 liters per hour.

The World Health Organization recommends 30 mL/kg over 30 minutes followed by 70 mL/kg over 2 to 3 hours.

WHO/UNICEF: clinical management of acute diarrhoea Opens in new window

Accounting for insensible losses is also important. For example, a 60-kg patient needs approximately 480 to 960 mL every 24 hours or 20 to 40 mL per hour to make up for insensible losses. For a 6-kg child, using an assumption of 0.3 to 0.5 mL/kg/hour, the maintenance is 2 mL per hour to make up for insensible losses.

Precisely calculating volume depletion is difficult. The equations provided may be used in balance with clinical judgment.

If intravenous fluid is not available, fluid can be given via a nasogastric tube in obtunded patients, providing it is possible to check the position of the tube post-placement (e.g., chest x-ray or litmus paper testing confirming acidic aspirated stomach contents).

Because the secretory diarrhea in cholera is high in sodium, potassium, and bicarbonate, Ringer lactate or Hartmann solutions (rather than normal saline or 5% dextrose) should be used. With the loss of bicarbonate and potassium in the stool, cholera patients have a profound metabolic acidosis and total body potassium depletion. With correction of the acidosis, the potassium concentration decreases further. Thus, potassium should be replaced through inclusion of potassium in intravenous or oral fluids regardless of initial potassium level.

Plus – supportive care

Back
ACUTE
|
vomiting or severe volume depletion
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Patients with severe volume depletion and those with high rates of purging (e.g., >1 L/hour) should be nursed on a cholera cot. Isolation of cases is usually difficult in outbreaks but essential in developed-world settings when returning travelers are being managed. The organism is not difficult to kill with standard cleaning agents available in medical facilities.

Plus – antibiotic therapy

Back
ACUTE
|
vomiting or severe volume depletion
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotics can reduce diarrhea volume and duration and shorten the period of Vibrio cholerae shedding.[96]

Current guidelines recommend single-dose oral antibiotic treatment for patients who: are severely ill; have severe, or some level of, dehydration with high school purging; are pregnant; or have comorbidities (e.g., HIV) that pose elevated risk in cholera illness.[44][96][97][98][99]​ Antibiotic therapy should be given as soon as the patient can tolerate oral medication.

Single-dose doxycycline is recommended as first-line treatment for adults (including pregnant women) and children. Historically, tetracyclines were contraindicated for pregnant women due to concerns about potential teratogenic effects, and for children younger than age 8 years due to risk of dental discoloration. However, a recent systematic review did not demonstrate such correlations with the use of doxycycline.[100]

While doxycycline is the preferred first-line treatment, the choice of antibiotic should be informed by local antibiotic susceptibility patterns. If resistance to doxycycline is documented, a single dose of azithromycin or ciprofloxacin is recommended as an alternative option.[98][99]

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[101]​ Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.

In low-income countries, antibiotic choice is likely to be limited by what is available in sufficient quantities to cope with high demand, and susceptibility testing is likely to take longer than the mean duration of illness, forcing empiric therapy. A wide range of antibiotics have shown activity against V cholerae, including tetracyclines (e.g., doxycycline, tetracycline), fluoroquinolones (e.g., ciprofloxacin), sulfa drugs (e.g., trimethoprim/sulfamethoxazole), and macrolides (e.g., erythromycin, azithromycin). Consult a specialist for guidance on choice of antibiotic if first-line or alternative treatments are unsuitable.

Primary options

doxycycline: children <12 years of age: 2-4 mg/kg orally as a single dose; children ≥12 years of age and adults: 300 mg orally as a single dose

Secondary options

azithromycin: children <12 years of age: 20 mg/kg orally as a single dose, maximum 1000 mg/dose; children ≥12 years of age and adults: 1000 mg orally as a single dose

OR

ciprofloxacin: children <12 years of age: 20 mg/kg orally as a single dose, maximum 1000 mg/dose; children ≥12 years of age and adults: 1000 mg orally as a single dose

Consider – oral rehydration and age-appropriate diet resumption

Back
ACUTE
|
vomiting or severe volume depletion
Consider – 

oral rehydration and age-appropriate diet resumption

Treatment recommended for SOME patients in selected patient group

Patients should be given a normal diet as soon as they are able to eat; including reinstituting breast-feeding as soon as possible after the initial catch-up rehydration phase has been completed.

Several types of oral replacement solution (ORS) are available: in the epidemic setting, the standard World Health Organization ORS come prepacked and contain (all in mOsm/L): Na+ 75, K+ 20, Cl- 65, citrate 10, and glucose 75, with an osmolality of 245 mOsm/L. However, if possible, rice-based ORS with a similar concentration of electrolytes should be used for cholera because this reduces the volume of purging. The use of polymer‐based ORS (e.g., rice- or wheat-based products) may be associated with reduced stool volume and duration of diarrhea compared with glucose-based ORS.[95]

Care should be taken in the epidemic setting to ensure that the water used for ORS has been boiled or appropriately treated.

Consider – zinc supplementation in children

Back
ACUTE
|
vomiting or severe volume depletion
Consider – 

zinc supplementation in children

Treatment recommended for SOME patients in selected patient group

There is little good evidence for vitamin and micronutrient supplements in treatment of cholera, with the exception of zinc in children.

A trial that looked at the effect of oral zinc supplementation in children with cholera found that zinc supplementation significantly reduced the duration and severity of diarrhea.[104]

The mechanism is likely due to an effect on enterocyte ion transportation, with zinc opposing the cholera-toxin-induced electrolyte secretion.[105]

Taken until recovery.

Primary options

zinc sulfate: children: 30 mg orally once daily

More

Consider – vitamin A supplementation in children

Back
ACUTE
|
vomiting or severe volume depletion
Consider – 

vitamin A supplementation in children

Treatment recommended for SOME patients in selected patient group

The World Health Organization recommends vitamin A supplementation for children above 6 months of age in resource-poor settings where malnutrition is likely to be a problem. Children with diarrhea in these settings are particularly at risk of vitamin A deficiency and should receive high-dose supplementation.[106][107][108]​ A Cochrane review has shown that in children ages 6 months to 5 years living in rural or urban/periurban settings, vitamin A supplementation is associated with a clinically meaningful reduced risk of all-cause mortality; specifically, with a 12% reduction in overall mortality and death due to diarrhea.[109]

Primary options

vitamin A (retinol): children 6-11 months of age: 100,000 international units orally as a single dose; children 12-59 months of age: 200,000 international units orally every 4-6 months

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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